For dialysis patients and staff at clinics near Moore, Okla., this week, the destruction from one of the largest tornados in U.S. history has left an unforgettable mark.

Researchers Hope To Recycle Kidneys To Help solve Donor Organ shortage

Nearly 20 percent of kidneys that are recovered from deceased donors in the U.S. are refused for transplant due to factors ranging from scarring in small blood vessels of the kidney’s filtering units to the organ going too long without blood or oxygen. But, what if instead of being discarded, these organs could be “recycled” to help solve the critical shortage of donor organs?

In Patients With Kidney Disease, LDL Cholesterol Is A Poor Marker Of Heart Health

Among patients with chronic kidney disease, those with very low kidney function had a higher risk of having a heart attack than those with higher kidney function over a four-year period.

Study Sounds Alarm Bell for Youth with Type 2 Diabetes

Some youths with type 2 diabetes have a more aggressive form of the disease than is seen adults, with a high risk for complications such as early renal and cardiovascular disease, according to a number of new reports from the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, which together form a special section of the June issue of Diabetes Care.

Acupuncture Points Useful in Diabetes Control?

ORLANDO — Diabetes patients with gastroparesis experienced significant relief of nausea with “needleless” acupuncture, which may have important implications for their glucose control, a small study suggests.

Could Statins Raise Diabetes Risk?
Some popular brands associated with high blood sugar levels in study, but odds of problems are low

Certain statins — the widely used cholesterol-lowering drugs — may increase your chances of developing type 2 diabetes, a new study suggests. The risk was greatest for patients taking atorvastatin (brand name Lipitor), rosuvastatin (Crestor) and simvastatin (Zocor), the study said.

Fresenius Wins Patient Case Management Awards

Fresenius Medical Care North America (FMCNA) has been recognized for outstanding health care case management with two “Case In Point” Platinum Awards from Dorland Health, the publisher of Case In Point magazine.

Sugary drinks tied to kidney stone risk

Adults who drink at least one sugar-sweetened drink a day are slightly more likely to develop kidney stones than people who rarely imbibe them, according to a new study.

Early prevention key message at Kidney Foundation AGM

Teach kids how to lead a healthy lifestyle and we’ll prevent a lot of kidney disease.

Kidney disease often goes unchecked

Despite one in three Australians being at high risk of kidney disease, the chronic illness remains low on the health radar of many people.

As most of you are aware, the OIG has been very interested in “cloned notes.” You know the ones I am talking about; you sometimes see them in the hospital or from referring physicians. Cloned notes tend to pull forward a tremendous amount of detail from the previous patient encounter; detail some would argue is not pertinent to the current patient encounter. Related to cloned notes is this issue of upcoding. Under scrutiny is the following question: Does template-driven documentation lead to the capture of excessive detail, which results in billing for a higher level of service?

In the article cited above, Jonathan Blum, Deputy Administrator and Director for CMS, states there is no evidence to date to support a correlation between EHRs and upcoding, but, “We have begun efforts to study whether there are differences in coding patterns for those who have adopted EHRs versus those who have not.”

Could this be a classic case of “which came first, the chicken or the egg?” EHR adoption rates are clearly on the rise, but the shift in coding patterns appears to have predated the widespread adoption of CEHRT. According to the ONC, EHR adoption rates among office-based providers was 17% in 2008, increasing to 25% at the end of 2010. In May of 2012, the OIG released a report entitled, “Coding Trends of Medicare Evaluation and Management Services.” Below I have put their numbers for office-based follow-up encounters into a bar graph. The graph displays the distribution by percentage among the five levels of service available for office-based follow-up care among Medicare Part B beneficiaries. Note the decline in 99213 and the rise in 99214 over the date span in this graph. To my untrained eye the shift towards higher codes started long before EHR adoption rates began to climb. By the way, the graph looks the same for new patient encounters, subsequent inpatient hospital care, ER visits, and a host of other code groups.

Medicare Part B beneficiaries: Office-based follow-up encounters by service type from 2002-2010

Part of the challenge is deciphering the less-than clear set of guidelines we are compelled to use when determining the level of service. Approaching 30 years of age, the 1995 and 1997 AMA coding guidelines, while written in black and white, occasional appear as multiple shades of grey, particularly under the scrutiny of a coding audit. Although I have made a habit of attending a nephrology-specific coding class every year, when the topic of E & M coding comes up, my eyes glaze over and my head begins to spin.

As Dr. Steven Stack, chair of the AMA Board of Trustees points out in the article referenced above, medical records were once designed to capture the provider’s findings and decision-making process. A patient’s record served as a point of reference for the provider and as a communication tool when collaborating with others involved in the patient’s care. Over time the medical record has morphed into a document that serves several other masters, including billing, coding, compliance and litigation.

Has EHR adoption been accompanied by a shift to the right in coding patterns? I suspect the answer is yes. Of course, historically physicians have been more likely to under-code and one could argue this trend represents a long overdue correction. However, if there is a message in this added scrutiny, I think it pertains to the cloned note. The copy and paste or auto-populate features available in almost every EHR on the market are popular time savers, but we need to be judicious in their use.

Primary cilia are found protruding from most cells in a wide variety of organisms, and defects in cilia have been implicated in everything from polycystic kidney disease to vision and hearing loss. In the kidney, they monitor the flow of urine; in the eye, they sense the wavelength of light; in cartilage, they sense pressure; and in the heart, blood flow.

Late to Bed, Late to Rise, Unwise for Type 2 Diabetics

Going to bed late, sleeping in, and eating a big dinner were all associated with poorer glycemic control in a new study of 194 patients with type 2 diabetes.

New Statistics Shed Light on ‘Worrisome’ Diabetes Epidemic

The prevalence of diabetes among US adults grew by 45% over the past 20 years, with the greatest increase seen among seniors aged 65 and over, according to a new study based on surveillance data from the US Centers for Disease Control and Prevention (CDC).

LDL Won’t Help Spot MI in Renal Patients

High LDL cholesterol levels were a weak predictor of myocardial infarction risk in patients with chronic kidney disease (CKD), a study found.

As a nephrologist or a professional working in a nephrology practice, I bet you think you are organized. I know I like to think that I am a very organized person. In fact, I have three loves when it comes to organizational skills. I love to label file folders and then fill them with the corresponding paperwork. I love to shred paper because doing so gives me a wonderful sense of accomplishment. Most of all, I love to make lists.

We all make grocery lists and guest lists, but I have an insatiable need to make to-do lists for everything. The question is, at the end of the day, what have I accomplished? I made a list and tasks were put on it. Along with a sense of accomplishment, lists help me to prioritize my day and have a calming effect so I can turn off my brain and sleep.

How to make an effective list

In order to be a successful list maker, you have to be a successful “task completer,” otherwise there is no real purpose of a list other than to procrastinate. I have found that if I write down four or five items I know I need to get done in a specified time frame, I should be able to accomplish them all. However, I do not allow myself to write down a) check voicemail messages, b) check email or c) answer phones. These are the daily things I do out of habit and would just be put written down for the sake of crossing them off; the repeated daily tasks have no place on a working list.

To be an effective list maker, follow this simple process:

1. Use a spiral notebook (or day-timer). This keeps the pages together so they can be flipped through easily.
2. Date the first page. This will allow a time reference if you need to refer to when the task was assigned.
3. Number the tasks and be specific. If a report needs to be done, name it (A/R, no-shows, billing reports, etc.) and give each report its own number.
4. Put a time limit on the task. This helps to prioritize the tasks on a daily basis and gives you a weekly log of what has been completed.
5. Re-organize the list. If #4 was not completed on the first day, then it becomes #1 on the list the following day.

Late-night list therapy

Sometimes I find that if I have had a busy day at work, I cannot turn off my brain at home and relax. I might be tired, mentally exhausted and ready for bed around 10:30 p.m., but as soon as I try to drift off to sleep my brain turns on. I find myself going through my day, particularly my lists, and wondering what I forgot to do. So, I get up and make a list. In this case, the list is comprised of everything that is swirling in my head. The simple task of writing down my thoughts allows me to again achieve that sense of accomplishment, and then relax and fall asleep. The best part of this list, however, is waking the next morning with hearty laugh as I try to decipher the scribble.

What an exciting time to be a nurse in our nation! During the annual National Nurses Week, we are reminded that nurses in every community are intimately involved in each patient’s journey towards better health and better care now and in the future. Health IT is a tool to help us and our patients in that journey.

Few African Americans receive kidney transplant from live donors

African Americans have seen a decline in live donors over the last 12 years, even as more of them receive kidney transplants, according to a study by Henry Ford Hospital in Detroit. Those findings were presented May 8 at the annual meeting of the American Urological Association in San Diego.

Mortality Risk Among Children Initially Treated With Dialysis for End-Stage Kidney Disease, 1990-2010

In the United States, there was a substantial decrease in mortality rates over time among children and adolescents initiating ESKD treatment with dialysis between 1990 and 2010. Further research is needed to determine the specific factors responsible for this decrease.

RRI Dialysis Times: A Time to Improve Kidney Care & Awareness in Uganda

In Uganda 717,970 people were estimated to have renal disease by the end of 2004 (US Census Bureau). The major causes of kidney disease were hypertension, diabetes mellitus, glomerulonephritis and infections including human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) (Kalyesubula R,2010).

Warfarin slows deterioration of renal function in elderly patients with chronic kidney disease and atrial fibrillation

Warfarin therapy may delay deterioration in renal function and improve survival of elderly patients with CKD and AF.

Dr. Ketchersid is taking a well-deserved break from writing the blog this week and I am honored to fill in for him today.

Throughout the spring, the Acumen team has been on the road visiting customers and prospects and, most importantly, educating attendees at trade shows. While shows like the Renal Research Institute (RRI) International Conference on Dialysis, the Renal Physicians Association’s (RPA) Annual Meeting, the National Kidney Foundation (NKF) Spring Clinical Meetings and the FMC Medical Directors Symposium are all big shows, the most important show for us will happen next month.

June 18-21, 2013, we are hosting the second annual Acumen Connect Users Conference, which will be held in San Diego. This is a huge event for us, as it allows us to give back to our customers. Not only will our customers have access to members of the Acumen team and opportunities to network with other Acumen customers, conference attendees get a first look at product updates and prototypes as well as the chance to provide feedback and ask questions in an enjoyable, intimate setting.

Last year, when we hosted the first Acumen Connect Users Conference in Chicago, we had no idea how many customers would attend or what to expect. We brought Acumen trainers, support staff, product experts and our executive team from all three offices to Chicago for a day and a half conference. We utilized Acumen superusers, contacted industry specific speakers and went out on a limb by hiring Bill Rancic as our keynote speaker. We were thrilled by the response we received. We had over 100 attendees, all of our speakers where extremely well received and we received nothing but rave reviews following the conference. In fact, the biggest complaint last year was that attendees wanted the conference to extend one more day and the class sessions to be longer. We were blown away.

This year we really want to take it up a notch. In addition to enjoying the seaside Loews Coronado Bay resort in San Diego, attendees will get to spend two and a half days with about thirty members of Acumen team, network with other customers and visit with Acumen partners. We have added sessions designed to bring customers together called “Connect Sessions.” No technology, just conversation. We are also featuring more customers-led sessions, training sessions and one-on-one access to our customer support representatives. Our keynote speaker will be Scott Rasmussen, president of Rasmussen reports and cofounder of ESPN, and industry experts will lead many of the sessions.

If you are already an Acumen customer, we hope you will join us in San Diego for the second Acumen Connect Users Conference. If you are still on the fence, we encourage you stop by and talk to our team at the next industry trade show to see how we can be your partner in technology.

Many eligible professionals (EPs) seeking to attest for stage 1 of the CMS’ meaningful-use EHR incentive program find that their biggest challenge lies with meeting the core measure related to protecting electronic protected health information (ePHI) maintained by their EHRs.

$13.7 billion in meaningful use incentives paid through March

The Centers for Medicare and Medicaid Services (CMS) has doled out more than $13.7 billion in EHR Incentive Program payments since the start of the program, according to the latest figures available for March.  255,772 eligible professionals (EPs) have receives payments so far, representing nearly half of the EPs in the country.  March saw $1.1 billion in payments to EPs and more than three quarters of eligible hospitals, signaling continuing success for the meaningful use program.

Good News About Organ Transplantation and Kidney Disease

Massachusetts General Hospital, one of the major research institutions in the United States and the same hospital that treated many victims of the Boston Marathon bombings, recently released a big breakthrough. Researchers created an artificial rat kidney in the laboratory that was then transplanted into another rat and ultimately produced urine — a huge advance in the field of bioengineering.

CKD Risk Lower in Big Water Drinkers

At the Canadian Society of Nephrology’s 2013 annual meeting, researchers reported on an analysis of data from the 2005-2006 National Health and Nutrition Examination Survey (NHANES) data showing that CKD was 2.5 times less likely to develop in people who drank more than 4.3 liters of water a day than those who drank less than two liters a day.

Work flow analysis critical after EHR purchase

An accurate mapping of the process patients encounter through clinical visits and care episodes helps practices identify waste and areas that need improvement.

The report specifically examines the national reporting experience between 2008 and 2011. As most will recall, PQRS started in 2007 with 74 individual measures and claims-based reporting. Nationally, about 100,000 providers participated in 2007; 55,000 were successful. As the program evolved, several alternative reporting opportunities were developed, including registry reporting, group practice reporting (GPRO) and EHR reporting. In 2011, the number of successful providers reporting PQRS exceeded 260,000.

Nephrologists favor registry reporting

The GPRO and EHR reporting options have not impacted nephrology, in large part due to the limited measure reporting choices. Nephrologists continue to report via claims, but an increasing majority of nephrologists have turned to registry reporting. Registry reporting became available in 2008. The graph below displays the number of nephrologists reporting PQRS using the claims versus the registry method of reporting. While claims-based reporting remains stagnant among nephrologists, registry reporting continues to grow in popularity. Our experience with Acumen PQRS suggests this trend will continue

Reporting success

I think there are a couple of reasons why nephrologists have migrated to registry reporting. The first is convenience. In contrast to claims-based reporting, registry reporting permits the provider (or more commonly his or her office staff) to enter the PQRS data retrospectively, using either data collection sheets or a chart-audit approach to data extraction.

Registry reporting is especially popular among nephrologists because of its success rates. Using the most recent figures from the CMS report, nephrologists reporting individual measures or a measures group via claims in 2011 were successful at a rate of 57 and 44 percent respectively. In 2011, nephrologists reporting individual measures or a measures group through a registry achieved success rates of 86 and 96 percent respectively. This substantial difference in successful reporting translates to larger number of nephrologists receiving the PQRS incentive when reporting through a registry.

Outlook for 2013

What can we expect for this year? I think demand for registry reporting will continue to surge. The CMS report notes that slightly over 30 percent of the nephrologists registered with NPPES  participated in PQRS during 2011. That figure is consistent with the national experience of physicians in 2011. Internally, we witnessed an increase in demand in 2012, which I found remarkable. In spite of the incentive dropping from 1.0 percent of the provider’s Part B allowable in 2011 to 0.5 percent of the Part B allowable in 2012, our registry experienced significant growth last year, and Acumen PQRS continues to be the market leader in the nephrology space.

For 2013 the incentive remains 0.5 percent; but remember, 2013 is the payment-adjustment reporting period for 2015. In other words, if you do not participate in 2013, you will face a 1.5% penalty in 2015. Without discounting the cash flows, it’s pretty clear that participating in 2013 is worth 2.0 percent of your Part B book of business. Of course if you believe in Prospect Theory, where losses loom larger than gains, participating in 2013 might be worth more than a 2.0 percent net gain for your practice. What are your plans for 2013? Respond to the survey and join the conversation.

CMS and ONC posted a joint fact sheet Tuesday that breaks down progress in health IT adoption since the passing of the HITECH Act, including the latest EHR adoption number and rates of e-prescribing.

Feds Still Not Happy About Meaningful Use Program

On April 23, six Republican senators sent a letter to Kathleen Sebelius, the secretary of the U.S. Department of Health and Human Services, and released a whitepaper, both of which addressed their concerns with the Centers for Medicare and Medicaid Services’ electronic health record incentive programs.

CMS’ ‘Meaningful Use 2′ Will Drive Pharmaceutical Content into Electronic Health Records (EHR) Systems

With more physicians spending more of their working hours interacting with an EHR system, the desire of pharma marketers to have some presence there (especially for “no see” doctors) is intensifying.

Acumen Introduces Nephrology Practice Management System

Acumen Nephrology has created a new nephrology practice management product, Acumen PM. The company said it would begin providing the product to beta sites.

The eRx nitty gritty

As a brief bit of background, recall the eRx program was separated from PQRS in 2009. The incentive peaked at 2% of the provider’s Medicare Part B book of business in 2009 and 2010. The incentive dropped to 1% in 2011 and it remained 1% for 2012. Also mentioned in this report is the 2012 eRx payment adjustment (penalty). 2012 was the first year a penalty was levied by one of the CMS incentive programs nephrologists face. The 2012 penalty was a 1% reduction in the Medicare Part B allowable for all services rendered in 2012.

Nephrologist participation ahead of the curve

One of the first things to note in this report is that a larger percentage of nephrologists have participated in the program compared with physicians in general. The bar chart below displays the percentage of eligible professionals participating in the CMS eRx program during the program’s first three years. The red bars labeled “MD/DO” represent all physicians. Note the substantial increase in participation between 2010 and 2011. This occurred in spite of a declining incentive (2% vs. 1%), and may reflect the impact of the looming 2012 penalty. Of additional interest, the 2011 figure represents 4,355 nephrologists among the 7,552 registered in the National Plan and Provider Enumeration System (NPPES) in 2011.

Percentage of Eligible Professionals Participating in the CMS eRx Program

Exceptions to the rule

What other nuggets of information are available in this report? I think there are several. A sizable percentage of nephrologists were not eligible to participate because less than 10% of their Part B allowable originated from codes that make up the denominator of the eRx measure (largely office-based E & M codes). In 2011, 14% of the nephrologists participating in the program failed to clear this 10% hurdle. In other words, although these 377 nephrologists successfully e-prescribed, they did not collect the 1% incentive because the vast majority of their Part B allowable originated outside the office venue of care. The same figure for the general population of physicians was 1.5% in 2011. This should not surprise us as a substantial proportion of the typical nephrologist’s Medicare Part B charges originate in other venues of care such as the hospital, the dialysis facility and, for some, the access center.

Participation pays off

Of additional interest is the amount of money this incentive created for the specialty in 2011. Almost 2,300 nephrologists collected about 7 million dollars for their participation in 2011. That is slightly more than in 2010, which is remarkable given the incentive percentage was only 1% in 2011 compared with 2% of the provider’s Part B allowable in 2010. This reflects the substantial increase in participation by nephrology between 2010 and 2011. Consistent with 2010, the 2011 figures suggest that for the nephrologists who particapted in 2011, the mean payout was just over $3,000. Stated another way, the annual Part B allowable for the typical nephrologist participating in 2011 was around $300,000.

Many still pay the penalty

One final note from this report relates to the 2012 eRx payment adjustment. This 1% Part B haircut was levied upon almost 136,000 Medicare providers last year. Sadly, 1,552 nephrologists were in this group. How did 20% of our specialty miss the boat here? A quick back-of-the-envelope calculation suggests our specialty left almost 5 million dollars on the table in 2011 because of this penalty. The larger 1.5% 2013 eRx penalty is in play now for some nephrologists. In 2014, the last year of the CMS eRx program, the penalty peaks at 2%. We have previously reviewed the CMS requirements to avoid the eRx penalty.

Three opportunities to avoid the 2014 penalty remain, and all require action prior to June 30, 2013:

1. Appropriately add the eRx G-code to any 10 Part B claims for services rendered if during that encounter a script was generated and transmitted electronically for the beneficiary.
2. Successfully attest to meaningful use for year 1 prior to June 30.
3. Register your intent to participate for the first time in the meaningful use program prior to June 30.

The bar is low for 2014. Let’s make sure our colleagues are not asleep at the wheel. Join the conversation and help us spread the word. The 2011 Reporting Experience contains additional information of interest to the practice of nephrology. Next week I’ll review the PQRS related content.