On July 29, 2019, the Centers for Medicare and Medicaid Services (CMS) issued the proposed Medicare Physician Fee Schedule (PFS) changes for the 2020 calendar year. 

A. Payment for evaluation and management (E/M) services

The E/M proposals will probably be the most complicated and will impact the most physicians. I will outline them here and then present a later Bulletin article dedicated specifically to E/M Services.

  • The CPT coding changes retain five levels of coding for established outpatient, but reduce the number of levels to four levels of E/M visits for new patients.
  • The code definitions are revised, as well as the times and medical decision-making process for all codes.
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Personalized, or precision, medicine promises a new paradigm of medical treatment, focused on individualized methods of disease diagnostics and treatment. Despite ongoing confusion about the meaning and interchangeability of both terms, personalized medicine broadly refers to “the tailoring of medical treatment to the individual characteristics of each patient,”1 while precision medicine broadly refers to the use of “omics” technology – emerging and ever-more complex genomic and proteomic tools – to identify markers that will subdivide patients into subgroups of expected response rates and facilitate individually targeted treatments.2 Implicit in these new terms is the idea of moving away from prior forms of medical practice: The terms alone insinuate that previously practiced medicine was impersonal and imprecise.

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It’s hard to share my perspective without a little bit of background information. Twenty years ago, I completed my dermatologic cosmetic surgery fellowship and worked with UPMC to open an academically based cosmetic surgery center. Over the ensuing 20 years, I have trained numerous residents of various backgrounds (dermatology, plastic surgery, ear, nose and throat, ophthalmology) and have had eight formal fellows. I have lived through the evolution and growth in this field. 

Yes, I have seen the worldwide interest rise for neuromodulators (Botox, Dysport, etc.), fillers (Restylane, Juvederm, etc.) and body contouring surgeries to say the least. However, the biggest change has been in the arena of light-based technologies, including a plethora of lasers, radiofrequency and ultrasound devices meant to tackle just about any problem.

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Articles

Editorial …………………………..282
I rather like you, and I don’t want you to die
Deval (Reshma) Paranjpe, MD, FACS

Editorial …………………………..284
Personalized medicine: Evolution, not revolution
Anna Evans Phillips, MD, MS

Editorial …………………………..286
Medical malpractice 101: A primer –Part IV: The expert witness
Richard H. Daffner, MD, FACR

Editorial …………………………..292
Is it really self-inflicted?
Andrea G. Witlin, DO, PhD

Perspective ……………………..294
Management of uveitis: A partnership between rheumatology and
ophthalmology
Jared Knickelbein, MD, PhD

Perspective ……………………..300
The fine line between functionality and cosmesis
Suzan Obagi, MD

The night of Tuesday, Sept. 3, was an unsettling one. Someone had tweeted a maddeningly specific yet nonspecific threat to enact a hate crime at a Pittsburgh hospital at 10:30 a.m. Wednesday. As it would turn out, the perpetrator was a juvenile male in Beaver County, who, according to news reports, had no intention of carrying out such a crime.

I found out about the threat at 10 p.m. that Tuesday night from a non-physician grade school friend who had kindly forwarded the warning to me as well as her other friends who worked in healthcare. That, to me, was the single warmest act of friendship I could imagine.

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We as scientist, as healers, have become distracted, divided, and it is easy to feel conquered by the outside forces of the corporate and legal practice of medicine. These forces have their own agenda. They will not lead science the way we should be leading it. We do not need to lose our leadership role in the scientific community. There is no one better to lead than us. We have shown this in the past, and we must not give up this role. No one can take it from us unless we remain silent. We have more educated people, more ways of communicating to share our thoughts and explain our ideas.

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Normalization of deviance is a concept first used to describe the NASA Challenger disaster. It refers to an insidious phenomenon whereby “people within an institution become so insensitive to deviant practice that it no longer feels wrong.”1 Looking back over the past several decades, we observe normalization of deviance within our U.S. healthcare system: serious problems that have slowly become ingrained into the culture. Examples include five-minute appointments, difficulty accessing one’s physician, lack of price transparency, complexity of coding and other documentation,2 and loss of physician autonomy and work-life balance.3 It is no coincidence that 2019 marks the first year in history that employed physicians outnumber independent physicians.

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Scenario #1. Your nurse is teaching an incontinent male patient to self-catheterize. His wife wants to record the encounter on her cell phone to “help” her husband perform the task in the future. The male nurse does not want to be recorded; he is concerned with his own privacy. Moreover, he is not sure that the patient actually wants his wife to film this. The wife is adamant that filming is necessary. The practice has plenty of other resources to assist the patient in completing this self-care task.

 

Scenario #2. You operate an OB/GYN practice. In your waiting room, a 12-year-old girl, whose mother is a patient of the practice, covertly snaps a photo of a 13-year-old patient when she is called back to the treatment area.

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Of all the reasons I’ve seen for selling a car, my favorite was the one a friend listed with his station wagon: “We outgrew it!” Just as his family needed more seats than the little Mazda could offer, our family has managed to cram two adults, three children, a giant fuzzy dog, and often an assortment of family and friends into our little townhouse … for a while. We stored; we stacked; we chuckled when we read about a family trying to find each other in their massive house. We might not know where we’d put one more chair when company came – but there was one problem we were not going to have.

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Recently, I was at an interdisciplinary team (IDT) meeting as medical director for a hospice. During the meeting, one of the nurses reported that one of her patients had a severe sore throat. She also relayed the information that her primary care physician (PCP) had declined continuing as her PCP once she became enrolled in hospice. By default, then, I was her PCP. Fortunately, I had time between the end of the meeting and my next appointment to stop by her house, which was not particularly out of the way. The patient was an elderly woman on hospice with end-stage chronic obstructive pulmonary disease.

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