Depression and its nasty little secrets

First of all, I am back after a long absence, I had lost myself in many ways. And as I typed that sentence, I wondered what it meant, and to be completely honest, I don’t know, but it seems like the correct and right thing to put.

Second, I hate the original name of this blog. It makes me sound desperate, but when I created the blog, it was the most original thing I could come up with, so however many years after I created this, I am stuck with it. Dear lord, I just looked and May 16, 2011, is the date that I first posted. I was looking for an outlet, and this seemed like a reasonable one. There are some decent posts, but why in the heck did my Fitbit stats post every day in 2013. I promise not to do that again.

Also, I have not been on this site in so long, I have no idea about this formatting crap that is going on. Why can’t I just pick a color, and size and type. Why is it changing with each time I hit the enter button? I guess I could hit help and settings and learn more, to learn more, but I probably won’t.

Anyway, to get back to the title and what I was really wanting to talk about, DEPRESSION. It is all over in society, and I would guess, 1/4 to 1/2 of my patients meet the criteria for clinical depression. Most don’t want to admit it to themselves, much less me. And no, internet trolls, it is not that they just feel sad. And it is not just standard grief, though the second has a lot of similar symptoms to it and can turn into it if they don’t grieve properly. And I am not saying there is a standard textbook way to grieve, it is individual, but if you don’t take care of yourself properly through this time, you will develop depression and may or may not be able to exit this state.

What I want to talk about is the overwhelming fatigue and inability to do even the most basic tasks to take care of yourself. I am talking about showering and brushing your teeth. Seriously, brushing your hair, even with a short haircut is exhausting. How do I know, because I have been there. I have been battling it for months. And even knowing what I know, it is a struggle, and sometimes that struggle is to do the very things you need to do, to pull yourself out of this deep hole.

How does one avoid these struggles? Fuck if I know. I overall have a pretty good life. I mean it isn’t all puppies and rainbows, but I have a good job, and make more money than I ever have. I actually turned down a sizeable raise because the anxiety that went along with thinking about it, put me into a panic. In hindsight, I should have taken a lesser raise which was offered, but in my mind at that moment it was all or nothing. And so, I chose nothing, or the baseline at where I was sitting. It is just for a year, and I will still be getting bonuses here and there.

So, is the issue my marriage? I don’t think so. I am married to a good, supportive husband, who does most of the cleaning. And he is supportive of my running adventures. He has put me on a budget in the past, because I was online shopping in the middle of the night, when I was not sleeping, and bought $500 of fairy garden gnomes and other such nonsense. I don’t even like gnomes or fairy gardens. And so somehow, I have myself trained that I can put whatever I want in my Amazon cart, but after 10 pm, I cannot hit buy. It is a good compromise. Because, while it has been a while, there have been some interesting things in my cart the next morning.

He is very supportive in other ways. When I threaten to quit my job, he lets me know that it is fine, but I will have to either stop spending so much or get another source of income to replace it. As of right now, I don’t have a plan. Additionally, I am actually good at my job, well the patient care part, the documentation not so much. And yes, I know the documentation part corresponds to patient care, but I do miss the paper chart of residency. Yes, I said it. Also, he wants me to have something to get up for, because he knows me well enough to realize, without a purpose I would not get out of bed. So yes, I do have a long-term underlying depression. I am on medications, I am getting better at taking, but I have a problem with my medication planner. IT DOESN’T FILL ITSELF!!! And while I almost always feel better after I run or other work out, it is a struggle to get myself motivated to start. Sorry Scientologists, vitamins and sunlight are not going to do it for me. Though I do have a happy light that I use during the wintertime, because Seasonal Affective Disorder will almost always make an appearance. I seriously don’t know how people live in Seattle. Great town to visit, but pretty sure I would become suicidal living there due to the weather.

So other things in my life, my kids. One is in college and living at home. The other is in high school. Both are typical boys. And while they will make appearances at mealtime, hanging out with me, or watching movies, not really what they want to do. And it is normal, and it makes me sad and proud at the same time

My parents are both reasonably healthy and recently retired. They live in another state but visiting is always an option. I don’t do it as much as I should, however. I last saw them in August when I did a run in New Mexico, and they are coming here for Christmas. My husband has 1 living parent, as his father died of cancer shortly after Easter. But his sister is taking the primary responsibility for his mom, so I am good there.

So why am I depressed? Health? Well, maybe a bit there. Caught Covid after a trip to Yellowstone. How did I do that? Well, I am guessing it is due to the lack of food places, due to staffing issues. Came back with COVID. But it started raining the day we left, so I will take credit for flooding the park. As if I have that kind of power.

All joking aside, I got fairly ill with COVID. Could only struggle to breath and sleep. Husband put alarms on his phone to make me use the nebulizer, I literally couldn’t function well enough to do that. And yes, I was boosted, made it 2.5 years without catching it. Primarily due to the vaccine. But Omnicron was enough different. Husband also had it, but only had an annoying cough. Fairly certain my oldest had a mild case, and the youngest, if he had it, was asymptomatic. All of us were boosted with the original vaccine. But back to me. I could not breath, I could not think. Husband contacted my boss to get a prescription of Paxlovid, which worked within 12 hours. Still had a brain fog, and fatigue, and mild shortness of breath, but hospitalization was not imminent. But after recovery, it took a month before I could even run a block. And since I was training for the London marathon, I was in a panic.

And the brain fog was even worse. For about 6 weeks, it was plain awful. Not sure how I took care of patients, but even after the 6 weeks it was still there. And to be honest, this is the first morning since June that I woke up fully rested with a mind that was awake and functioning, no fog. So, my medications are back at a good level, because there was an issue with that also, most of it being my fault, some the DEA, some the insurance company and a small bit the doctor’s office. But mostly mine.

Additionally, I didn’t want to pay for my eczema medication at $1000 a month. I can afford it, but it seems ridiculous, and I am also confused about how the co-pay card only helped for 2 or 3 fills when it has an upper limit of $11K. Makes me think that my specialty pharmacy that I have to use, for this medication per my insurance, decided to not pay for it at all during that time, and then just decided to use the copay assistance 3 times, since the cash pay price is $3500 for 2 doses. Yes, I said that correctly, 2 doses, or a one-month supply. I tried to deal with them during my brain fog and lack of ADD medications, and maybe or maybe not, my Cymbalta, but I just ended up hanging up on them. And then went 3 months without medication. I could go on about this, and the ridiculous cost of medications, especially since the FDA has an orphan drug pipeline, which helps to pay for these niche drugs, but that is an entire pile of worms that I don’t want to get into.

But back to the depression, so you could say I have been in a slump, more days than not for the past few months. I was actually honest on the PHQ 9 form given to me by my doctor. I also stopped sleeping. Terribly tired, couldn’t sleep. I blame the lack of Adderall, because when I take it regularly, I sleep like a baby at night. Basically, when it wears off, my brain turns off. Maybe not completely, because my watch, which is a Garmin and my OURA ring, seem to think I sleep terribly. The ring thinks I am doing slightly better than Garmin does. But both like to lecture me in the morning.

But this morning, I was wide awake at 6 am. I have only minor aches and pains, and my brain felt clear. IT was odd. So, my hypochondriac part of my brain started trying to figure out what was wrong. And nada. So next I tried to figure out what I did yesterday to cause this. A good 5-mile run, a decent diet, drinking water, took my medications, all of them, and a good night’s sleep. I have done some of that the past 6 months here and there, but maybe the fog is lifting. I had energy to take a shower, brush my teeth, and use the water pic and floss. Don’t get me wrong, I was still brushing my teeth, before I left the house, and most nights, but the flossing and water pick did not happen. I am not ashamed or afraid my dentist will read this, because at my last cleaning, I told them that I didn’t floss.

Another change, I am planning to go to a friend’s house at 2 pm. And I am not currently trying to figure out how to get out of it. That is my norm. Last week, I made dinner reservations for my husband and I, and Sunday, I cancelled them, after asking if he really wanted to go, because I did not want to leave the house. I know I have an issue that if I am supposed to do something, I have to do it before getting to my house, or I will not do it. An exception would be like going to vote this past week, I ran to the house to pick up my oldest, so he could vote for the first time. But I was in and out in under 5 minutes, my car was still running in the parking lot, and I had not taken off my shoes. That is the only way I can leave my house once there, is it has to be super brief, and I cannot sit down, and I must leave my car running.

I am not sure what else to say here, but to tell others, I see you. I know it is hard somedays to get out of bed, shower, brush your teeth and hair, and make yourself presentable just to function. I see those of you who go through the motions, and I understand. And I know how hard it is to get yourself outside for a walk, to the gym, or even to the exercise bike in your own living room. My treadmill is at the end of my bed, I literally don’t even have to leave my bedroom to get on it. And yet, somedays it is the biggest most difficult journey of all.

In response to GSK verdict

The recent verdict of Glasco Smith Kline really should mean little to me.  After all, I have never taken payment from them.  There might be the occasional lunch so they could pitch their product to me, but I finished residency after the first set of Pharm D laws were passed.  Actually I think that I might have been in medical school when they were passed, but in residency when they went into effect.  What does this mean?  Well, I have never taken a trip to Hawaii on a drug company, I have never gotten a membership at a fancy golf course, nor did I ever accept any money from them.

In the interest of full disclosure, I believe that either Merck or Pfizer paid for my graduation from residency (It has been 7 years, and the program was responsible for details) I have received numerous meals, and pens, and writing tablets.  Did these items influence me?  Maybe, if I am writing a blood pressure medication, and the pen that I was writing with was for a blood pressure medication.  But I would have to believe that it was effective.  I wouldn’t write Norvasc (amlodipine) for a patient in heart failure for example, because they already have problems with swelling.   But most of the time, I didn’t even think about the pen in my handle.  Mostly because it is a stylus that only works on a computer and is black without label.  I rarely use a pen except to sign the few prescriptions that I cannot send electronically.

As for samples, yes I utilize them.  Before the antidepressants started going generic, it was nice to be able to give a patient a two week supply to see if a certain medication was going to work, prior to putting out cash for a high dollar prescription.  Now that there are generics, well that is typically the first choice I write for.  If the generics don’t work, well then I make my next selection with what I can give the patient a sample for, because it is nice to try a medication without spending an ungodly amount, only to find that it doesn’t work.

Now why the verdict means something to me.  With the announcement the Dr Drew Pinsky took at least $275,000 to “provide services for Wellbutrin” (whatever that means) the internet has lit up with claims that this is what physicians do.  They are all on the till for Big Pharma.  Slate online discusses Dr Drew and then implies that most doctors collect checks from Big Pharma.  Lew Rockwell (the founder of the Mises Institute) actually says on his blog “Here is much of the medical profession in a nutshell, since most doctors are in the pay of Big Pharm from medical school onwards.  They get commissions for all those drugs they tell you to buy.”  I guess my check is still coming, since I have yet to see one, yet.

Now it is easy to blow off the likes of Lew Rockwell, since I don’t know if there is a conspiracy that he doesn’t believe (that is my opinion) but his large following is where the problems come in.  He has some of the most rabid of followers and even helps to continue the vaccines cause autism fallacy.  But he is only one of many that are helping to spread the idea that all doctors accept payment from Big Pharma.

Why Dr Drew accepted money from GSK to promote Wellbutrin should even register is beyond me.  He is one of a growing number of charlatans who have traded their respect for media fame.  Dr Drew is worse than most, in that he has also traded on the fame of his patients who are struggling with addiction to create television.  The man let’s face it appears to be a media whore.  I don’t know where in the Hippocratic Oath the statement of except in the case of a television show comes in, but apparently it is there.

I don’t have a problem exposing those that do take commissions, maybe we should be more transparent.  I don’t mind discussing with patients why certain medications would work better for that patient than others.  It is part of my job.  But there are times that the generic is not the best choice for the patient, or maybe there is not a generic equivalent, but this should be a conversation that I have with the patient because it is for the good of the patient, not because some blogger without a medical degree has decided that the whole profession is suspect just because there are a few (alright more than a few, but no where near the majority) corrupt practitioners.  Based on the blogs I have seen on the issue, I have been convicted merely because I hold a medical degree.

Few physicians receive payments from the pharmaceutical companies.  An occasional meal for listening to a drug lecture or spiel but rarely anymore than that.  In fact, I don’t know the last time I accepted a dinner from a drug rep due to preferring to spend my evenings with my children and running them to their activities.  As for those who are paid to promote their drugs, there is supposed to be disclosure for doing so, both in lectures at Continuing Medical Education events.  And believe me, every rep tells me their drug is better than their competitors and all of the generics, I have a medical degree, I think I can figure out that they are in my office to sell their product.

My thoughts on ObamaCare- insurance exchanges

If you are anything like me, your Facebook page, twitter feed and everyone you meet have some opinion on the Supreme Court’s decision on the Affordable Care Act, otherwise known as ObamaCare.  And it is either the best plan ever or the worst decision and Justice Roberts is a traitor to his country, and blah, blah, blah.  Well that was Thursday.

Friday, it was well if we don’t overturn this mess, I am moving to Canada, Australia, Costa Rica, or other English speaking, industrialized nations all with some form of Universal Healthcare or Socialized medicine.  Also countries with a tougher immigration policy than we have, so I am not sure that unless you are super wealthy that is actually an option.

And then there is the stand by the Republican governors to not enact an exchange because they will fight this to the bitter end.  You all know that the exchange was originally a republican idea don’t you?  And probably my favorite part of the bill.  Why?  Well because I own a small business, I have 8 employees, when I started I had two employees, my husband and I, which accounted for a pool of 4 people.  Why does that matter, because when I went to purchase insurance in 2005, I was 7 months pregnant, covered under a policy which I COBRAed through the hospital that I did my residency in.  At $750 a month.  Now I was just out of residency and started my practice on my own, and well $150,000 in debt from medical school, with a new baby on the way.  So I looked for something, and the best I could find that would cover that baby was $1500 a month.  They could not deny me pregnancy coverage as pre-existing at the time, because I live in a states that if I had insurance that previously covered a condition within the last 6 months, there was no pre-existing condition.  However, do NOT ever shop for insurance when 7 months pregnant.

I called 4 insurance agents, and several companies on my own, the best that I could do was to COBRA my current policy ($750 a month) until the baby was born and then start the following month with the new insurance.  Though I actually COBRA for one additional month, because there was some question as to coverage of the brand new baby.  Anyway, this policy I could afford was roughly $400 a month per person in pool, oh and it didn’t cover pregnancy.  And I had an employee who would like to have a baby, so we changed our pool to three, and I covered her on an individual policy, that would cover pregnancy a year after it started.  (Which didn’t work because as it happens, she stopped trying to get pregnant and she had a baby 11 months after the policy started, and ended up on Medicaid for the pregnancy anyway)

Now being as I had insurance for all but my 3rd year of medical school (I had gotten married and could not stay on the plan, and well we couldn’t afford it until my husband started his internship year and it was covered) I could not believe the difference in rates.  I saw what had been taken out of my check at the hospital while I was employed, and it was not that much.  I talked to others as to what they paid working for bigger companies, and the talked the agent, and what the answer was the size of the pool.  My pool was three, and one was diabetic, I was a bigger risk, than those with thousands of employees, who could afford better coverage for less.  But if I got to 5 in the pool, or 10 the rates drop significantly, and then if I have 50 employees, well that is an even better drop.

But with an insurance exchange, here is the deal.  Let’s say your exchange becomes the state for instance.  Larger states might decide to have multiple pools, or smaller states might decide to join into a regional pool, doesn’t matter.  The pool becomes big enough that smaller businesses or the individual could choose a plan that actually works for them within their budget.  If you want to cover pregnancy care, great, here is the plan for you.  I don’t cover it for my employees because it would increase my costs $200 a month per employee, and that includes the two males, who if they become pregnant, I think I would sell their story, me who has had a tubal, and another employee or two that are menopausal.  There was only two of my current employees that would even desire pregnancy, and well at $1600 a month, well it is not even affordable for me to do so.  And as it stood before, they could not even add the coverage as an option because my pool is too small.

While I would have preferred for the market to develop something like an insurance exchange on its own, it is highly unlikely under today’s highly politicized system, it ever would have.  An insurance exchange would allow for those healthier to choose coverage to benefit them better, would allow for people to choose coverage for preventative care.  At least it would ideally, but it would also allow for those with diabetes and other chronic conditions to find a plan that would cover them.  I didn’t say that they all had to cost the same in my world, but prior to ObamaCare finding a plan with a pre-existing condition was impossible without high deductibles, and being astronomically expensive.  And then there was a year of paying for the plan before it would cover any pre-existing condition, so you can understand the frustration for those that tried, and for those that decided against buying insurance.

Like I said, I look at it from a small business who while not required thought that it was right to cover my employees.  I am in healthcare after all.  I actually like this part of the ACA, there is much of the plan that I don’t.  But the opposition to this part, is something that does not make sense, yes the free market should have produced it, but it didn’t.  But this is a natural progression of medicine since the development of Medicare and Medicaid, a natural progression from EMTALA.  I find myself frustrated at both sides on this issue, the surprise that the bill stood, the gloating that this bill is the best thing ever (it is not).  In the last 6 months it was obvious it was going to stand, and if not most of the major components were going to be put in a new bill.  Besides an estimated 60% of the costs in the infrastructure to support the system had already been put into place.  Repealing it would have been of little use.

That is just my two cents worth.  But what do I know, I merely own a small business and see patients everyday.  Do I agree with the plan in whole, no.  But I don’t see the alternative offered by the other side as much different.

To all those graduating residency this month (or close to anyway)

OR What I wished someone told me when I was about to graduate.

Congratulations, welcome to the world of medicine.  Does it seem a little belated?  After all you have been licensed anywhere for 2 to 5 years depending on your specialty, you graduated from medical school and have been officially a doctor for 3 to 6 years, not to mention the 4 years of medical school before that.  So while I grant you it seems a little belated, it is not.  You are now officially on your own.  There is no back up.

For the last 6 months or so you have been counting down the days, the nights on call, weekends on call, or some variation until you were done.  You have taken board exams, presented research and have either had a graduation or are about to have a graduation that is not quite like the ones from medical school and college, but they are still nice, and they are still a big deal.  (I seemed to have forgotten that, and didn’t think to invite my parents to mine.  Whoops)  But you have been counting down the days until your time in now your time and you don’t have to answer to anyone else.

And a funny thing happens, the moment you graduate, you instantly become one of us.  In a way you weren’t before.  Those that are staying close to the program that they graduated from will find it a little more amazing the change from resident to the next morning ATTENDING.  And for the easy stuff it is amazing.  Ear infections, I got that.  Hypertension, well I will use my favorite ACE or beta blocker.  You have bronchitis, and you will be super doctor until “What the heck is that?”  Well that is what you will be thinking, and you will have to stop yourself from saying “I am going to grab my attending to come in here and look at that.”  Because you no longer have an attending you are the attending.  So you will pull out your books or go online to your favorite site and you will figure out to your best opinion what it is.  And if you are right, you will be a hero, and if you are wrong well they will either return and you will try something else, or they will go somewhere else.  You are now the EXPERT.

But don’t think that you are alone.  I made that mistake.  The profession is quite willing to help its fellow physicians, you only have to ask.  Which EMR is best, ask.  Most are more than willing to let you look at their systems and try them out.  You need help with a case in the hospital, you can either officially or unofficially consult one of your colleagues, we love being asked for advice from fellow physicians.  Just don’t ask investment advice, some are really good at it, and some are really bad, best to find a financial advisor on your own.

Make sure you have a good accountant, a good lawyer and a good relationship with a bank.  Seems silly, but those will save you time and again especially if you are starting out on your own.  Rare now a days.  I did it 7 years ago, and it is probably due to the accountant and bank that I am still standing.  You didn’t go to business school, you went to medical school, but school and residency failed to teach you about the business of medicine.  And it is a business.  You want to get an MBA, great idea in a few years.  The first couple you need to work on getting your feet wet in the medical field.  So surround yourself with a great support staff.

Your spouse/significant other who went through all of this with you, was not trained in billing and coding for the most part.  So if they are going to run your business, they need to get trained.  While the motivation is their (It’s their money too) the knowledge may be lacking and you are probably not qualified enough to teach them.  They need to either get some training or hire someone who is trained.

Take time off.  No not the first month, but you cannot go constantly.  It does not serve you and it does not improve the care you provide to your patient.  And all of  your patients are going to get sick and they are all going to be mad that you left them when they were the sickest ever, but that first day back your lobby will be filled because that guy down the street that was covering you, just doesn’t know what they are doing.

And if you are at the program you trained at DO NOT ever in that first year use the line. “When I was a resident…”  Most of the program was just a resident with you, and it loses its meaning when they can come back and say, “You were a resident just last month.”  My fourth year in medical school, I witnessed that from one of the new attending, who went around saying that.  You can say it after everyone who was ever in residency with you has graduated, but until then, they knew you in residency.

And if you use that line don’t follow it with something ridiculous like “I would have liked to get up at 2 am and do an H&P if my attending would have asked me to.”

No you wouldn’t have, and you didn’t like it.  You complained to your fellow resident the next day.  There are crappy things that residents have to do because they are learning and are residents don’t insult them by pretending they aren’t.  And remember you were once a resident, don’t just abuse them because you can.  It doesn’t make you a better doctor among your colleagues.  It just makes you an ass.

This list is far from exhaustive, and I am sure if I had time I could keep going, but I don’t and this blog is getting a little long.  So congratulations on your achievements and hard work.  And welcome to the club.  You membership fees are now due.  (This is only half a joke, you have no idea how expensive it becomes to keep all these groups fees paid)

The Obesity Epidemic

I don’t know if epidemic is the right word, since it is not an infectious disease, but the rate of growth that it is spreading (no pun intended) certainly mimics an epidemic. From “The Weight of a Nation” documentary recently shown on HBO 1 in 3 children that was born in the year 2000 will develop Type 2 diabetes” Those numbers may seem ridiculously large to the general population, but in my patient population in rural America, lower socio-economic population, it is hardly surprising, other than I might estimate it closer to 1 in 2. Scary, isn’t it? And I don’t think it is because I am a bad doctor, and I don’t think it is because of bad parenting (or at least not intentionally). It is a combination of a lack of education, loss of physical education, a loss of parks and ability to play outside, and the easy availability of fast food and other quick processed foods.

In my practice, I see all ages from 2 weeks to 94 (I think that is the age of my current oldest patient) And throughout the group there is a definite problem that spans the generation. Now am I going to focus on diet and nutrition with the 94 year old, probably less so, but on those that are younger it is very necessary. Today, I had a long talk (or three of them) with patients who told me that they didn’t know why they gained weight or didn’t lose this month. They aren’t eating anything. First of all, I am going to call you on that one. It is physically impossible to gain weight, if you don’t eat anything (I including drinking in the eating). Now once you become morbidly obese, your metabolism does slow down significantly, and it is more difficult to burn the calories that you do take in, but really you have to be honest with yourself about the intake.

Please stop saying that you eat a normal diet. You don’t. How can you? I don’t even know what a normal diet is anymore? The diets that get described to me when I finally get them to tell me what they are eating are far from my typical diet. A large slice of Cheese Pizza from Pizza Hut has 390 calories. (One slice) Multiple that by 8, and 3180 calories are found, which is more than anyone needs in a day, much less a meal. (And yes, I do have patients that eat that as their meal. Well, no, I don’t, it is a supreme pizza or pepperoni) And I am not saying that I never eat pizza, merely that it needs to be in moderation, it is not a terrible food, but really needs to be done in a portion size.

And a portion size can Fit in the palm of your hand. (Give or take) A serving size of meat is about the size of a deck of playing cards. I don’t care it you can eat the 72 ounce steak from the big Texan, that is 12 serving sizes of meat. Hardly healthy. I find that the type of meat you eat is less important than the size and method of preparation. Frying fish, takes out all the heart healthy benefits that are found in the Mediterranean diet. Those Omega 3’s are drowned in a sea of saturated fat.

If you go to the grocery store, a nutritionist that I know, told me shop the edges. All the unprocessed foods are on the edges, fruits, vegetables, milk, cheese, deli, etc. Even the frozen food section with the frozen fruit is often on the edge. You don’t need the mac and cheese, the canned meats, and the like. If it can’t go bad, it probably should not go into your body in any significant amount.

And at the very least keep track of the calories you are taking in. We are terrible as adults in estimating the amount of calories we consume. The journal of Clinical Nutrition estimates that we underestimate our calorie consumption by as much as one third. So if you think you are eating 1800 calories, it is very possible that your intake is closer to that of 2400 calories. Over time that adds up. We are not as bad as kids. Think about it, children who are not forced to clean their plates, tend to stop when they are no longer hungry. Those children tend to be leaner.

We have shut off our thirst mechanism, and instead believe it to be water. It takes 20 minutes for your body to realize that it is full. So if you eat slower and chew your food, you are bound to get up from the table eating less calories. However, during the day, that hunger pain you feel? Well if might not be a hunger pain at all, but your thirst mechanism. By the time you feel thirsty (dry mouth) you are already partially dehydrated. So I tell all my patients, make sure that you eat, in portion sizes, but if you feel hungry, take an 8 ounce glass of water and drink it, wait 30 minutes. If you are still hungry, then eat. This would cut down on quite a bit of intake.

I also see several people who say that they can’t eat until 10 pm, so that is why they retain their weight. Well, I am not quite as tied to the rule of no food after 7 pm for them. Why did this weight loss gem come about? Think about what the “typical” American does after 7 pm. They are tied, so they sit down and watch television. (For those of you whom this does not apply, well that is great) And what do you grab while in front of the television? Fruits and vegetables? Hardly- that is when the junk food comes out in the greatest quantity. Eating an apple at 9:02 pm is hardly going to ruin your diet, but eating a whole tin of Pringles and washing it down with a 20 ounce Mountain Dew, well that is not so good. There are legitimate reasons for not eating that late- reflux tends to be worse in those that eat within two hours of bedtime, and your activity level does decrease so their is some slowing of the metabolism, but seriously if you eat 1200 calories throughout the day, you will probably lose weight, regardless of whether you have your dinner at 10 pm or 5 pm.

And those sodas- just stop. They are empty calories and sugar. And the diet ones are less calories, but artificial sweeteners and both trigger your appetite and make it difficult to manage your portion size.

And for those of you in the South. That sweet tea, which is mostly sugar, well that is not helping either. It is not helping you hydrate, and there is little benefit from it. So other than occasionally, really don’t down it thinking that it is healthy.

And then the gorilla in the room, EXERCISE. At some point we as a nation stopped exercising. Our kids no longer get to play outside, Physical education programs are cut, and with the lack of exercise they see their parents doing, is it any wonder that our kids are growing larger? Type 2 Diabetes, a disease previously named Adult Onset diabetes is becoming more and more common in this group. And if they are not diabetic, they are insulin resistant so they are within 5 years of the diagnosis of diabetes. We have got to get our kids (and parents) moving. Kids learn more from watching their parents then from anything that they say. You can’t expect your kid to exercise, if you don’t get yourself moving. And it doesn’t have to be running. Walking is good, Bike riding, roller blading/skating, swimming or anything else that you find enjoyable. But get up and move.

I like to suggest a pedometer. They range in prices from around $5 to the $99 one from FitBit. I actually own the Fit Bit one, and while you might ask, “Why would anyone pay $99 for a pedometer?” I like mine because I can keep track of it online. Add to it the FitBit app for my iPhone, and I can keep track of my meals and my exercises, and they recently came out with a scale that will link with the site. Allowing for all of the sats in one place. It is nice, and convenient. But regardless, a pedometer is nice, because you can shoot for 10,000 steps a day. It is difficult not to lose weight if you take 10,000 steps in a day. And if you have that goal, you know where to shoot for. And that is something that everyone can do.

We all need to worry about obesity. Especially as it helps to escalate health care costs. There are great bariatric surgeries available but they are not without risk, and really wouldn’t you rather prevent the need for surgery and the complications of obesity for both you and your children?

;

My data on the calories from a single slice of cheese pizza of 390 appears to differ from that posted on the Pizza Hut website of 360 calories. I should have gone to the website itself than using a different more general website.
As for the statement that diet sodas have less calories, it is true that they have no calories. I was more illustrating that drinking them over regular soda you eliminate the empty calories but recent studies are showing increase in the risk of heart attacks and may stimulate your appetite, and may cause you to gain weight in the long term. This is the result of a recent study from Harvard University

Allergies and why they matter

As we travel through this allergy season, I am actually having an easier time of it than usual, in what is apparently one of the worst in Southeastern Oklahoma in several years.  Due to the lack of a cold winter, we did not have the period to kill off the normal plants and decrease the load, so I have a great deal of patients in my office complaining of allergy symptoms that in many instances never had.

What exactly are allergies?

According to the Institute of Public Health allergies are defined as “an exaggerated immune response or reaction to substances that are generally not harmful.” 1.   The key to that definition is “generally.”  Because of that word we are aware that there are those that are harmful.  Today more than ever we hear about children who have anaphylactic reactions to foods such as peanuts and nuts.  And yes, I did mean to separate them, because a peanut is technically a member of the legume family and not a nut at all.  Other foods that commonly trigger an allergic reaction include shellfish, eggs, wheat, milk and soy.  These are not always as serious as anaphylaxis but they can be.   Today there is a big attempt to remove milk from the diet, and creates gluten free diet, and unless you are a celiac (allergic to the binding protein in wheat, rye and other common grains) it is found to be a limited benefit in others.  However, limiting your gluten intake may make you feel better, if only due to removing most of the processed food from your diet.  And for those that are allergic to soy, well this diet would cause more problems than not, since many of the replacement foods contain soy.

Another issue that is appearing with soy is that in males in may lead to hypogonadism and infertility.  Now these studies are early and they are still looking closer, but one of the beliefs is that the link may be the result of soy breaking into down into estrogen like compounds and at least temporarily decreasing the sperm count.  Soy can also as I learned in the past week cause anaphylaxis.

 

This picture is actually my son, 30 minutes after his school gave him a large dose of benedryl, which may have been more than the recommended dosage, but with his whole face swelling up, I think it was the better of the two choices.

I myself have food allergies, and hay fever, and everything else that goes with it.  I spent years wearing long sleeves in hot weather, and other ridiculous things to hide arms so that I didn’t have the ridiculous questions about the “track marks” on my arms, and “how I couldn’t hit the vein.”  This is my arm today

This is my arm today.  It actually is relatively under control  Yes you can see the eczema- but there are only a few spots that are terribly red and irritated.  And there is the scratch on the arm.  Must have done that in my sleep.  I am better most days now that I am older and more aware of the damage that I do so I can at least attempt not to scratch.  Those white spaces scarring from the years of scratching.  It makes my skin fairly tough, and hard to take blood, well at least getting through the skin- once through the veins are right there.  But this is enough of an issue that I had to argue with the people at the blood back that they could take my blood.  I mean there is a blood shortage, and you want to not take my blood because of a little scar tissue.  Once the needle is in the vein it all comes out the same

Anyway, other than the unsightly skin, and itchy, watery eyes, and sneezy nose- why do allergies matter?  I mean if those reasons are not enough.  The National Institute of Public health states that most children outgrow their allergies- I am not so sure.  I haven’t outgrown mine yet.  But the Allergy and Asthma Foundation of America estimates that allergies cost $14.5 billion a year.  This includes the direct costs of $1.3 billion for office visits and $11 billion for medication, both prescription and over the counter.  The rest are the indirect costs of missing of work and decreased productivity.  “For adults, allergies (hay fever) is the 5^th leading chronic disease and a major cause of work absenteeism and “presenteeism,” resulting in nearly 4 million missed or lost workdays each year, resulting in a total cost of more than $700 million in total lost productivity.” 2  This makes allergies the 5th leading cause of doctor visits in the United States.

If possible removal of the allergen is recommended for those that suffer from allergies, and those that suffer heavily may benefit from allergy testing and immunotherapy.  At the very least, there might be an improvement in the allergy sufferers quality of life.

 

 

1. “Allergies” A.D.A.M.  Medical Encyclopedia  PUBMed Health  last reviewe October 2011, obtained online at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001815/(May 6, 2012)

2. Allergy Facts and Figures.  Asthma and Allergy Foundation of America found online at http://www.aafa.org/display.cfm?id=9&sub=30 (May 6, 2012)

 

 

Attitude is everything

Or my self serving whiny post, which does nothing, teaches nothing, and is merely in existence for no other reason than it makes me feel better.

Sometimes I have days like today. Where when I walk into the room, and ask the patient how they are doing, and today is the worst day of their life. If it is one or two, well that is well not ok, but feasible, because at some point you will have the worst day of your life. This morning however, it seemed like it was everyone’s worst day ever. It improved somewhat this afternoon, in that only half of the patients were having their worst day ever, the rest just have multitudes of complaints

In reality, dealing with a couple patients who view everyday as the worse day ever is tiring, a whole morning is exhausting and mind numbing. It is enough to wish for a fully stocked bar in the office. (I said wish, I rarely drink, so much more that a glass or two of wine would make for a bad idea, especially in the middle of the morning, er I mean the afternoon.

Anyway, it is in those patients you realize how important one’s attitude is to their health. Patients who believe that everyday is terrible never seem to be getting better, and while it might be my doctoring skills, I have patients that seem to improve. So that gives me some hope for my skills. I have patients who have their diabetes under control, their blood pressure looks good, and sometimes walk in and say “I am all better.”

And then there is the others. The ones that despite running ALL the possible tests, you still cannot find a reason for their worst day ever, which by the way is worse than their previous visit that was also the worst day ever. They have pain that is a 12 on a 10 point scale where 10 is being caught on fire currently. And then the mention a random surgery were half of the bowels were removed 15 years ago, that they forgot to mention previously. (Not really, pretty sure I would have seen that scar) But there are unmentioned surgeries, medications, and dietary factors that they neglect to mention. Or other doctors that are prescribing medication. (Sometimes the same medication and sometimes one causing side effects that you are treating.)

And then when you do the workup for a condition, you find out that even though their symptoms scream gallstones, they had that removed 5 years ago, and well they didn’t think it was important to mention. I mean after all they no longer have that organ so how can it be the problem? Though I have been told that they didn’t mention it, because they thought that it might have grown back.

Back to the attitude mentioned in the title. Those with an overall positive outlook in life really do seem to heal better, they are healthier. They try, they are not hoping for a magic pill to cure all. And some of them have significant medical diseases. They have the belief that things can get better, that there is something in life worth living for. And they are living life. This does not mean that they don’t have pain. They may, they might not, but they are trying to experience and live. There is some purpose to their lives.

It is not that they don’t have pain in their lives, some have significant tragedies. Death of spouse, child, fighting disease, but they are looking for a greater meaning. They accept that bad things happen, and maybe just maybe these events help you to appreciate the good times. The understand the need to experience everything that life has to offer. And just by seeing them, you feel better. They make your world better just by them being in it.

Attitude is not the end all, cure all. But it is a necessary component to improve one’s life. It helps with healing, it helps to give strength and motivation. It is what makes one successful in life.

My 5010 nightmare- maybe coming to a close?

It has been a little longer than normal since I have posted, and my excuse is that I have been busy.  Not that everyone else hasn’t been, but well work life seems to have been busier than normal.  Previously, I have written blogs about a firewall that was blocking payments and how I could not get through, and that maybe things were finally getting better and they are.  This week we finally got our first check from Medicare for claims since 12/19/2011.  It was for $12.45.  Woohoo, I can finally retire!

I laugh because I actually think that it is hilarious, all this time and work, and complaining about not getting paid for almost 3 months, and when we finally get through, the amount is not quite the amount you expect, because the deductible started over on January 1, and most of the claims on that sheet went to deductible.  All this work and time waiting, listening to the crickets chirp.  Or wishing their were crickets chirping, because it would be something better than silence.

After this time, arguing with the clearing house about their responsibility only to be told to look at their website, which for the longest time said absolutely nothing, and then eventually outdated and somewhat misleading information.

First it was my fault, no, it wasn’t.  I did all the steps, I was told were required for a smooth transition.

Then it was my EMR vendors fault.  Well,. they sent me a new update on January 1, which was downloaded within that week.  Followed by one more update the end of the month.  So maybe slightly- though I did send them a not so nice email as well during my frustration, to which they replied within 10 minutes intially, and then 5 more times within 30 minutes and able to fix the problem by the next morning, and considering it was 5 pm when I sent the first email, I was happy enough with their response.

So that takes me to the end of January, where the clearinghouse has yet to notify me of any problems, or to answer why I have not heard anything in a month from ANYONE (insurances included) to looking at my balance sheet saying “Holy (insert profanity here)!  Why haven’t I gotten paid.  How am I going to make my bills, pay my employees, …”  To only get told I am 1700 in line with a waiting time of 7 and a half hours.  Well that was when their system did not cut me off and hang up on me.  And after all that time I was on hold what was their answer.  “Well you should look at our website daily.”  Well at least they are consistant.  Though they continue to refuse to answer my question “how can you take my money without at least warning me that there is a problem?”  Their answer is still I am sorry for your difficulties and your disatisfaction, but we post things on our website daily.  You should read that.  And when I threaten to leave them, it isn’t any better.  Still with the damn website quote, and does not answer my question, and that I am required to give them 30 days written notice.  Which I will, as soon as I know I am up and running with the new group.  Just have to wait for Medicare approval.

Finally, the clearing house appears to have gotten their job done (only 60 days late, and not willing to take any responsibility).  However, that day Trailblazer crashed.  Nice.  It takes them about 4 or 5 days to get back up and going, and then we get messages that we are not an eligible provider.  Apparently even though Medicare claims that our contract is still good so far this year (we will have to renew this year, it is just not our turn yet) Trailblazer has forgotten to tell us, we need to sign a new form.  OK done.  Now for the new denials- all of our claims are duplicate claims.  Seriously?  It is a wonder, I haven’t gone postal yet.  All of this, filing and refiliing, denials and everything else to get the anti-climatic check of $12.45.  Awesome

However, I have gotten in contact with some great people that have helped.  Apparently, I helped my professional organization find out there was a problem, and they narrowed it down to Trailblazer having the biggest issues.  They determined that the physicians in Oklahoma and Texas appeared to be having the biggest problems.  Talking to some billers across the country, those using a clearing house seemed to have more problems than those that didn’t.  So guess what?  I had both issues.

And in the middle of this all, apparently Trailblazer is installing new software to help fix the problem (which apparently started last year)  I have heard from my congressman and Senator and one state Senator, but since things are improving we are hesitant to have them do anything.  Because there is no desire to cause further stalling on the issue, especially now that payments (did I mention $12.45) are finally slowly coming in.

As for my relationship with my clearinghouse- Well it will come to an end when I receive approval from Medicare for my new billing company to file how the prefer to do it.  After 6 years, I think it is time, and my loyalty apparently means little to them.  But I did let my colleagues in the area know that their clearinghouse was at least partially responsible for them not getting paid.  Helpful website indeed.

But I had good news on Thursday, I finally had enough money to catch up all of my bills.  I didn’t have to take out a loan.  I still didn’t get to take home a paycheck, nor did my husband, but maybe next month.  It is really sad that Wednesday, I saw 40 patients, and my hubby saw 33 patients in the office and 7 in the hospital, and we were longing for the days that we saw 17 and took home a paycheck.  But maybe as things start rolling, we will be able to see some of what we have worked for.  I hope so, because I didn’t go to medical school hoping to support 6 other people and not get paid myself  (we are now down 2 employees, after one dying at the beginning of the month, and the other being fired).

Anyway, as the computer glitches resolve, we will move foward.  Looking ahead to the crashes and glitches that will come with the conversion to ICD-10.  Oh happy days ahead/

Dear Center for Medicare and Medicaid Services

This is an email that I would send to the Center for Medicare and Medicaid Services, but since they don’t have an email address for themselves, unless I want to report fraud on either myself or another, well I will have to make do.

 

Dear CMS-

I would say that you don’t know who I am, but you have used my picture for the last year advertising your EHR Incentive program as the first clinic to receive the Incentive Bonus from Medicaid.  So you must at least have an idea of who I am.  That being said, you probably don’t care, but at least you know that I have tried to play by your rules in order to win that honor.

Couple that with the calls a couple times a month from the Office of the Inspector General looking for the physician whom we  agreed to become custodian of record for, well you have talked to at the very least my office staff.  And we have given you all of the information we have.  OR have at least indicated just let us know what you want, we believe that she left the country, given you the email addresses we have, but we don’t have what you are looking for.  Well other than the patients version of what she did.  But otherwise you have not had many dealings with me.

I have a practice of 45% Medicaid and 25% Medicare.  So all together about 70% of my practice is receiving “insurance” from your office.  Over the past year, we have done all of your recommendations for 5010 conversion, and per you and our systems passed them all.  We have performed the required updates, installed the needed hardware, software, implemented the required training, all that you have indicated as necessary.  So based on those, we were ready for the conversion January 1, despite the delay to March 1, 2012.  However, you decided to implement the conversion on December 19, 2011 and installed a firewall.  This firewall blocking all new claims from going through.  We didn’t notice it right away, due to a 2 week to 45 days delay from date filed to date paid.  So we didn’t notice.  Add to that the notification that claims would be delayed about 2 weeks, well it took a little while.  25% is a large chunk of income, but it would have been ok, for a short period of time.

On December 28, the firewall went up for Medicaid.  Again there was a slight delay in noticing, since the turn around is two weeks, plus we were told that there would be a two week delay.  However, this was somewhat more painful.  Added to that the insurance companies have all installed required firewalls, however, after three weeks, we are finally through and getting paid.  So we are receiving payment for 30% of the work that we do.  That does not even cover my staff or overhead.

My understanding is that I am not alone in this problem.  It is neither EHR vendor specific nor clearinghouse specific.  The only constant is that they are plans paid for under your umbrella, Medicare, Medicaid and Tricare.  And one message received was that I was fortunate, at least my problems only started in mid-December, not early November like some physicians.  Whatever.  I have not taken a paycheck since the middle of December.  That is no paycheck for either my husband (also a physician) and me.  Still had to make payroll for the staff of eight that I employ.  Well currently seven, due to a recent death.  But even she received a paycheck this last pay period.  So I have had enough to pay 8 people, well up until this week.  This week, I had to pay some staff out of personal accounts.  So now, not only am I working for free, I am paying for the privilege to deal with government regulations and bureaucracy.

Oh and did I mention that I experienced the privilege of an audit by Oklahoma Medicaid during this time, which other than a few minor problems, I passed.  One of those being something that I have no control over, being specialists not sending their consult notes to go with the referral that they got paid for, but somehow that is my deficiency, DESPITE CALLING AND ASKING FOR A NOTE!!

So anyway back to the point of this message that you will neither read, nor receive, but maybe someone out there will hear me.  I paid for the pleasure of working last week, PERSONALLY!!  And I wonder why I constantly have a headache, and the gnawing of an ulcer in my belly.  I own my clinic, and am personally responsible for the debt to go into business.  I don’t have a big corporation that can afford a short period of time to cover not being paid.  My clinic sees 68 patients on average a day, so I should not have a negative balance sheet, but I do because for 70% of them, I have not seen a dime since December 28, maybe a few more due to the small amount of TriCare that I also see.

I know that I am not the only one who is experiencing this, since this week we were 2017 in line when calling to see where the problem was.  (We were 1700 last week, and that ended with 7 and a half hours on hold, only to be told to check online for solutions, WHICH WERE NOT THERE!!!)

I scraped enough for payroll this week.  In two weeks, I may be able to do it again, even without payment.  But after that I will be done, I will have no choice but to close my doors.  I understand the theory that you should love what you are doing so much that you would do it for free, but I did that the first 18 months in practice, and 6 months in 2010, and an occasional pay period here and there.  But I cannot afford to do that for much longer.  And I definitely cannot afford to do it and pay to do so.  Currently I have $120,000 in Medicaid Accounts Receivable since December 28, and another $60,000 in Medicare. (that is not what I will receive, only what I am billing)  And if by some miracle that were to come through tomorrow, I now have back bills and creditors who would also like to be paid, so even if you were to fix it tomorrow, I will be working for free until May or June.  So my husband will have to spend more time away from his boys, and work more shifts in the ER so we will survive.

I know to some, this is what I deserve being a greedy doctor, though I have yet to make over $100,000 personally since graduating residency.  (My declared income is higher only because of my husband working in the Emergency Room)  I have bills to pay, and cannot afford to continue floating the payroll for the clinic.  So I am asking CMS to look at their firewall, and attempt to fix it, or the looming doctor crises will come in about 2 or 3 months instead of the 3-5 years that is currently anticipated.

 

P.S. If this is your plan to save Medicare, it is a really crappy thing to do.  You should look closer at where your biggest incidences of fraud occur, and not cause those who are playing by the rules to become financially ruined.

CMS blocks payments to providers through firewall

The Centers for Medicare and Medicaid services have found a way to save money.  They simply installed a firewall which blocked claims submission from providers who have complied with the 5010 conversion by January 1, 2012, which was their initial deadline.  And the best part, most providers did not realize the problem until the end of January.  In what has been one of the worst weeks in my life at the office, we received a phone call on Tuesday, from another office who used the same EHR and the same interface processing claims asking if we had been paid this month from either Medicare or Medicaid.  The answer was, yes.  Well initially it was yes.  Followed by “Well only by Medicaid.”  Followed by, “Well outside of our medical home payment about $18.22.”

WHAT!

Throughout this month, I have been watching the income come in.  And until about the middle of the month, it was about the same as last year, maybe even a little more.  And while I was not thrilled with that considering there was more patients 45 days before than there had been a year ago, money was still coming in.  And we had already found that there was a problem with a glitch in our billing and were attempting to locate it.  So I was already not taking a paycheck this month.  So at least my salary was not affecting the outgoing.

However, as the month went on, that number seemed to not change the way that it was supposed to.  Well, we are looking for it on the one hand, but last Thursday, we underwent an audit from Medicaid, so much of our effort went to preparing for that.  Making sure that all of our i’s were dotted and our t’s were crossed.  Knowing that no matter what they would find something wrong.  Realizing too late, that after our last COLA inspection, our CLIA certificate seemed to not be put back in the same place, and was currently MIA.  Which is not great news, especially since a computer glitch at CLIA has not allowed them to send new certificates out, and we are still waiting today for the request submitted two weeks ago.

So anyway, while the numbers were concerning, they were not in the front of our mind, until Tuesday.  When a call partner called, and we looked.  And then discovered.  We had not heard anything from our clearing house all month regarding claims.  So we examined further, and that $18.22 was from Medicaid secondary payment which was submitted to Medicare prior to January 1.

So we called our interface to find out what happened.  “You are currently 1,746 in line.  Approximate wait time is 7 hours 32 minutes.  Did you know that you can check wait times online visit www….”

Well that sounds, uh promising.  After utilizing a phone line for the entire day, we found out, that there was the problem, they were contacting our EHR, and no they don’t know when it will be fixed.  That was tuesday.

Wednesday, we found out that it was not just our EHR having problems.  It was multiple EHRs.  And we started looking for a new way.  We had recently hired a new billing company, who was in the process of creating tunnels and whatever else is required for them to extract our data over the internet and bill for us, would they be able to take our Medicaid claims and submit them an alternative way?  The answer was maybe, if we can figure out how to extract them from the mess, we currently were in.  (Then tragedy struck our office Wednesday afternoon, and to be honest, we just tried to finish our day)

Thursday morning, numb and still in shock, we checked by on the Gateway.  Still no payment, but there was something that had not been there in a month.  A screen of rejections.  We don’t know if that is a good sign or not, but it was something new.  Still no payment.  But a new screen.  And the interface was still working on the problem.  (However, this did not prevent them from drafting my account for payment earlier in the month)

Finally, Friday morning came some answers.  Calls to Medicaid to make sure that we would not get hit with a penalty for attempting to file claims multiple ways, which received a probably not, also had some news.  Apparently the day before, they received 18 electronic batches through interfaces.  While they did not know if they were ours, they said it was promising only because they had not received anything the entire month of January.  Nice.  And you could not have said anything to your providers?

And Friday morning, also provided word from our clearing house.  Apparently the 5010 conversion had caused this.  Despite providers, software vendors and electronic interfaces having had successful tests from the previous year, January 1, conversion did not go as planned.  A firewall at CMS enacted for this event, did not recognized claims that were in compliance or not.  It did not recognize NPI numbers, ICD-9 codes, or CLIA numbers.  In an essence, those who complied with the rules by the initial deadline were penalized and just not paid.  This included all federal government programs Medicare, Medicaid, and Tricare.  Well actually Tricare was worse, their firewall had been blocking claims since November.  And our situation could have been worse, there were Medicare providers who had not been paid since November.  And this is for those that comply with their rules.

Unfortunately for me, 45% of my income is from Medicaid, 20% from Medicare, and Tricare <1%.  So you can imagine what this is doing to us.  The only thing good with regards to Medicare is that we collected their deductibles up front, so we did get some of that.  Though there were also glitches with Blue Cross Blue Shield which is our 3rd biggest payor, which has a percentage close to that of Medicare.  So I guess that I am lucky that I am sitting at half of the number that I should be.  Next month figures to be worse, when you consider a 45 day wait time for Medicare on average.  If we can get claims through under Medicaid, I should get paid in as quick as a week after submission.

So the month of January, I have worked for free.  February, I will also not be taking home a paycheck, and I imagine it will be close to May, since March and April will require me to catch up on bills not paid this month due to the CMS firewall.  Which means more shifts in the ER for the hubby, so that we can survive at home, since my bills won’t stop.

So those of you who think physicians are just greedy, and should be willing to take a 27% cut in pay from Medicare (which would result in similar cuts from other insurances) consider this.  My overhead does not decrease, it increases.  I still have to pay my staff, rent, electric, water, etc.  And following this incident for being in compliance… it is no wonder that physicians don’t trust CMS.  I have not committed fraud, and have played by the rules.  But situations like this sometimes makes you wonder why you bother.

So before any of you call your physician greedy or just in it for the money, think about this.  Those that are self employed didn’t get paid this last month at all, and will probably not get paid this month (take home pay).  The fact that they don’t trust CMS results from issues such as this.  And that is not even looking at the cluster that is ObamaCare.  So I worked last month seeing patients for free, will next month as well.  Sometimes you have to wonder if that time wouldn’t have been spent better elsewhere.

So I guess CMS has come up with an ingenious plan to save money.  Just block physician claims from going through at all.  That way, their money is able to stay in their account and draw interest, and well unless providers close their doors overnight, their patients are still being seen at least temporarily.  So if you look at the numbers for January for CMS, I am sure they look the best in a decade.  Thanks CMS.