Teaching the blind to see; Dec. 2004

Beaumont Lecture: Doctor teaches blind to “see”
By PAUL NATINSKY
Managing Editor
It almost seems like something out of science fiction. Imagine a blind man “seeing” a ball roll across a table and reaching out to stop it – using a camera wired to sensors on his tongue!

Well, 200 physicians saw a video of this feat, courtesy of Paul Bach-y-Rita, MD, at this year’s WCMSSM-sponsored 83rd Annual Beaumont Lecture, Nov. 5 in Troy.

Dr. Bach-y-Rita, a Professor of Rehabilitation Medicine at the University of Wisconsin Medical School, has been conducting successful experiments since the 1960s on what is best decried by the title of his lecture: “Sensory Substitution for Vision Based on Late Brain Plasticity.” In other words, teaching the blind to see using alternative pathways.

“The brain is enormously plastic,” said Dr. Bach-y-Rita. “As little as two percent of remaining undamaged tissue can serve as the basis for total brain reorganization.”

In the case of “sight,” a surprisingly small number of contact points are placed on tongue. The electronic impulses are transmitted to the tongue cuing the patient about which direction an object is moving. It works like a form of radar.

The sensations are not painful. Dr. Bach-y-Rita said they have the feel of champagne bubbles on the tongue. He said the sensations are not annoying or distracting. As a matter of fact, they become unnoticable after the patient has worked with the sensors for a while.

Much like when a blind person uses a cane to navigate, the sensations that come back through the stick become a substitute for the brain’s use of sight stimuli. The brain adjusts or “reorganizes” and understands the sensations as sight impulses.
Sight is not the only disability that can be ameliorated by Dr. Bach-y-Rita’s methods. He has worked with patients who suffer from balance deficiencies, facial paralysis, and touch insensitivities. He said he can find an alternate pathway to the brain for any patient who has a sensory deficit.

Dr. Bach-y-Rita continues to try and bring his therapies and research into the medical mainstream. He moved from being a pure academic to becoming a medical doctor and from research into clinical settings. But the progress of acceptance is slow despite the fact that the treatments are inexpensive and can be conducted in informal settings.

“We can’t claim that we don’t have the money for these programs, because they are very inexpensive,” he said.

2004 WCMSSM Children’s Holiday Party Contributors
Drs. James & Sophie Womack 
Dr. & Mrs. Robert C. Hawley 
Dr. John and Sheila Roarty 
Dr. & Mrs. Daniel B. Michael Marjorie Stewart Gagliardi, MD 
Dr. & Mrs. Gordon M. Murray in memory of Dr. & Mrs. A.A. Ulmer 
Henry and Maralyn Domzalski 
Metropolitan Eye Center-Dr. James W. Klein & Associates 
Hassan Amirikia, MD  
Dr. & Mrs. Reginald Harnett 
Drs. George and Nadya Kazzi 
Michael Kleerekoper, MD  
Dr. & Mrs. Francis Nazareno 
Rosser Mainwaring, MD  
Drs. Guat and Dionisia Sy  
Taufiek Alhadi, DO   
Frank P. Bongiorno, MD  
Robert A. Songe, MD  
Jeff & Wendy Page   
Dr. & Mrs. Ron Strickler  
William Davis, MD   
Wilbur & Rebecca Smith  
Orlando S. Sison, MD  
Robyn Arrington, Jr., MD  
Dr. & Mrs. E.C. Bush  
Dr. & Mrs. A. Michael Prus  
Alan & Edna Drucker  
Fred Nelson    
Darlene & Hugh Henderson 
Nathan Segel, MD   
Vern & Jane Strand   
A.T. Lebamoff, MD   
Dr. & Mrs. Philip Wolkok  
Catherine Nordby, MD  
Drs. Munther & Beth Ajlouni 
Dr. & Mrs. Harold E. Usndek 
Dr. & Mrs. Gilbert B. Bluhm 
Richard & Edna Shin  
Mrs. Nicole Price   
Richard F. Heldt, MD  
Nancy E. Gregory, MD  
Dr. & Mrs. James G. Fordyce 
James and Anita Leisen  
Robert G. Borchak, MD  
Karen Chapel, MD   
James A. Rowley, MD  
Dr. and Mrs. George Shade 
Jacques M. Rosenfeld, MD 
Jean Jaffke-Whitney, MD  
Vincent Yu, MD   Halim Haber, MD   
Mazen Khalidi, MD   
Joan & Bob Allaben   
Helen A. Papaioanou  
Dr. Alex P. Kelly, Jr.   
Suzanne White   
Henry W. Lim, MD   
Drs. Lisa and Scott Langenburg 
Abdelkader Hawasli, MD, FACS 
Elizabeth Secord  
Joseph M. Beals, MD 
Dr. Richard and Gail Smith 
Rosemary Bannon 
Henri Pierre-Jacques, MD - Orthopaedic Specialist 
Dr. & Mrs. Edward Jankowski 
Andrew J. Sulich, MD  
Timothy A. Brennan, MD  
Robert G. Borchak, MD  
Natalia M. Tanner, MD  
Dr. William G. Nutting, MD  
Clarence H. Schultz, MD  

Lest we forget Pearl Harbor
By GILBERT BLUHM, MD
Today, Dec. 7 63 years ago, cannot be forgotten by some of us! Japan attacked Pearl Harbor!

WWII began for the USA. There was nothing about it in the Wall Street Journal or the Oakland Press today.
That fact surprised me. Why should anyone NOT want to remember it? Hawaii remembers.

I remember clearly that Principal Carl Porter called my seventh grade to join everyone in the High School Auditorium. We listened to President Roosevelt at noontime Dec. 8, announce by radio the dastardly attack which "will be remembered in infamy."  The next four years featured a Selective Service Draft, Civilian guards at a nearby electric power plant, rationing, heartaches for those families who lost loved ones in war battles, and the atomic bomb.

Subsequently, after being drafted as a physician for the Navy during Korean "war", there was a Medical Corpsman who was at Pearl Harbor during the Japanese attack. He was 17 years old at that time. His description was not unlike scenes in the movie "Tora, Tora, Tora" made in the late 1960s. The Executive Officer where I was stationed also had harrowing experiences when the Yorktown Aircraft Carrier was destroyed in the Pacific Ocean.

December 1975 was my first visit to Pearl Harbor and trip to the Arizona Battleship Memorial as well as the Veterans’ Cemetery on Oahu. These were a few of my indelible memories of the aftermath of Dec. 7, 1941. I shall not forget "Pearl Harbor."

UAW PPO vouchers create confusion
In a letter dated Sep. 9, 2004, BCBSM stated that it would not take action against physicians who choose to bill patients their full office visit rate instead of the discounted "PPO" rate for enrollees in the new UAW PPO contracts.

Despite that statement, the BCBSM vouchers will not identify which patients are in the new auto PPOs – and because the new UAW PPOs are not the only claims processed on the NASCO system, physicians who are billing their patients full charges may inadvertently take write-offs for patients they may not have intended to take write-offs for.

Physicians will need to identify those patients in the new auto PPOs in their computer system so that it shows up in their payment posting screens. This way, the staff person posting the rejection will know whether or not to take a contractual write-off. 
When an office visit is processed for the new Ford, DaimlerChrysler and GM PPOs, no payment is made to the physician by BCBSM. The payment voucher shows the physician's charge in one column, the PPO approved amount in another column, and the PPO approved amount in the subscriber liability column (since BCBSM assumes patients will be charged the PPO rate). 
In the message that explains how the claim was adjudicated, it states that there is a subscriber co-payment, but it does not indicate that it is one of the new UAW PPOs. The only indicator that a claim may be for a patient in one of the new UAW PPO plans is if the approved amount is the same as the subscriber liability. Even then, the practice would need to verify whether that patient has a deductible, since some plans pay office visit charges only after the deductible has been met.

If your practice is using an electronic posting function, you will need to work through your vendor to address this issue.
For more information about reimbursement issues, contact Stacie Saylor at MSMS at (517) 336-5722 or ssaylor@msms.org.

Editorial: What Is Ahead
By JOSEPH WEISS, MD
Editor
The Bush administration can claim another four years. Not only did Bush win the presidency, but the Congress contains a clear Republican majority. In addition, the federal judiciary all the way up to the Supreme Court, is cast in a conservative state of mind.
We will face a federal government that, for the next four years, will remain dedicated to the marketplace as the arena for solutions to health care problems. The federal government's attitude will be to let the people decide. Government funding to the states, including Michigan, will adopt the same attitude. That is, states likely will obtain block grants for health care. States will receive a specific amount of federal money and each state will decide how to spend it. Given the budget deficit, the amounts provided to the states are likely to be limited and long term, i.e. be smaller than states deem necessary and be given without increase for a four- to six- year period.

The Medicare Modernization Act just passed this year is not likely to undergo change, particularly with the increased Republican majority in the House and the Senate. Changes for tort reform are good, but opportunity for improving prescription coverage or decreasing drug cost for the elderly is unlikely. The administration will no doubt do more to help the development of private Medicare. Even with the looming budget deficits, the possibility is good that Bush will increase subsidies to private health insurers to further the cause of taking Medicare out of the government realm and into private hands.

How will this political environment play out for us practicing medicine in Southeastern Michigan?
We are likely to feel the effects in the following ways:

To ask for more money for Medicaid will both waste our resources and antagonize politicians. We will need to work with Michigan Medicaid as it now stands. The state's present job-loss climate only compounds the problem of limited funding by the federal government.
-The Detroit/ Wayne County Authority will need great acumen in its effort to gain federal funding. The problem is made worse as Michigan did not go for Bush in the November election.
-We will see more implementation by health insurers of strategies that will "Pay for Performance." The health care sector will take up the mantra of applying business methods to medicine. The experiment of incentive pay will intensify as backers of the concept push to gain the efficiency outsiders believe medical care lacks.
-Michigan Blue Cross will pursue its present course to increase control over doctors. The Blues have reason to believe that the present atmosphere, both in public and in the courts, will support its aggressive efforts to box in the medical community.
Given the above, our strategy is clear. First, we must organize with even greater intent than in the past. Lobbying in Washington will take on great meaning both for federal funding and administrative interpretation of the Medicare Modernization Act. The role of lobbying in Washington of our sub-specialty societies will be of particular importance. Physicians fees will not significantly improve, the only improvement in reimbursements will come from increases in what Medicare will pay for procedures.
Second, we must accept that the burden of caring for the uninsured will continue to fall on us.
Finally we will need patience as we will be dealing with a federal administration that will continue to be secret, dogmatic, rigid and disciplined.

WSU names medical school dean
Dr. Robert R. Frank, associate professor of medicine and associate dean for academic and student programs at the Wayne State University School of Medicine, has been named interim dean, effective Oct. 25. He succeeds Dr. John Crissman, who stepped down recently as dean.

Dr. Frank has been a member of the School of Medicine faculty since 1977 and, as associate dean, has guided the shaping of a comprehensive medical curriculum. He also is currently leading a drive to raise funds for construction of a new medical education building at the school.

"We are pleased that Dr. Frank has agreed to lead the School of Medicine during this exciting time of transition and progress," said Wayne State University President Irvin D. Reid. PhD "His longtime association with the medical school, as both a faculty member and key administrator, further equips him for this important role as interim dean."
 
According to Nancy Barrett, Wayne State provost and senior vice president for academic affairs, Dr. Frank will provide the necessary leadership to maintain the school's missions of education, research and patient care while a national search is conducted for a permanent dean.

I am confident that Dr. Frank will provide the vision and direction to keep the school on its charted path of growth during this interim period," Barrett said.

Dr. Frank's major clinical interests are in geriatrics and end-of-life care. He was the chief of medicine at Detroit Receiving Hospital from 1983-1985 and he co-founded the Palliative Care Service at the hospital.

He earned a bachelor's degree in biology from Brandeis University and entered Wayne State University as a medical student in 1968. He served his internship and was chief medical resident at Detroit General Hospital.
Wayne State University is a premier institution of higher education offering more than 350 academic programs through 12 schools and colleges to more than 33,000 students in metropolitan Detroit.

Search Committee Announced
Nancy S. Barrett, WSU provost and senior vice president for academic affairs, announced the School of Medicine Dean Search Committee.
Dr. Gary Abrams, chair of the WSU Department of Ophthalmology, has agreed to chair the search. The following faculty, hospital affiliates and student have agreed to serve:
-Richard Cole, executive vice president and chief administrative officer, Detroit Medical Center ;
-Joseph Dunbar, chair, WSU Department of Physiology;
-Robert N. Frank, professor (with tenure), Department of Ophthalmology;
-Chris Gappy, student, School of Medicine ;
-David Kessel, professor (with tenure), Department of Pharmacology;
-Mary Kramer, associate publisher, Crain's Detroit Business;
-Gwen Mackenzie, executive vice president and chief operating officer, Detroit Medical Center ;
-Stephen Migdal, professor (clinician-educator), Department of Internal Medicine;
-John C. Ruckdeschel, president and chief executive officer, Karmanos Cancer Institute;
-Maryjean Schenk, chair, Department of Family Medicine;
Beverly Schmoll, dean, Eugene Applebaum College of Pharmacy and Health Sciences;
-Jack Sobel, professor (with tenure), Department of Internal Medicine;
-Bonita Stanton, chair, Department of Pediatrics;
-Ronald Strickler, OHEP, chair, Obstetrics and Gynecology, Henry Ford Health System; and
-Judith Whittum-Hudson, professor (with tenure), Department of Immunology/Microbiology.

Final Medicare fee schedule includes drug repricing and billing information on new Medicare benefits
Compiled by: Medical Group Management Association, Government Affairs Department
www.mgma.com, govaff@mgma.com

The Centers for Medicare & Medicaid Services (CMS) released a 842-page pre-publication version of the 2005 final Medicare physician fee schedule on Nov. 2. This annual publication includes payment rates for covered services as well as changes to Medicare policy. Importantly, the rule includes the 1.5 percent increase in average Medicare physician reimbursement for 2005. This increase represents the minimum amount approved by Congress in last year's Medicare Prescription Drug, Improvement and Modernization Act (MMA) as a result of extensive advocacy by the Medical Group Management Association (MGMA) and others. Without this mandated minimum, physician practices would face a 3.3 percent cut for 2005.

The Agency provided a chart of how the revisions to codes and the payment update affect providers by specialty and type. The chart and a link to the pre-publication document are available on the MGMA Web site in addition to a full-analysis of the rule.

Early estimates for drug rates posted by CMS
Beginning Jan. 1, outpatient drugs will be reimbursed at 106 percent of the average sales price (ASP). In a separate rule, CMS established that pharmaceutical companies will report each quarter their 12-month average sales prices, which include volume discounts, prompt-pay discounts, cash discounts, free goods that are contingent on purchase requirements, chargebacks and other rebates. The third-quarter sales data will be used to set the annual reimbursement rates for physician-administered drugs paid under the ASP formula. MGMA anticipates the final reimbursement rates to be published in mid-December.

In concert with the fee schedule release, CMS supplied providers with estimates for reimbursement rates of several top drugs used by Part B providers. These rates were taken from second-quarter data and are not final. These second quarter drug reimbursement rate estimates are posted to the CMS Web site.

The final fee schedule rule also includes revisions to drug administration codes and billing rules, in addition to details on a one-year demonstration project for oncology practices. For calendar year 2005, Medicare will provide additional reimbursement to oncology practices that measure and treat pain, nausea, vomiting and fatigue in chemotherapy patients. CMS has established 12 new G-codes for practices to report these services.

One-time physical and screening for cardiovascular disease and diabetes covered
Jan. 1 for Medicare beneficiaries
The 2005 Medicare Physician Fee Schedule final rule includes new preventive benefits for patients approved in the MMA, including a one-time physical for new Medicare enrollees, diabetes screening and cardiovascular screening blood tests. MGMA will continue working with CMS to ensure that clear coverage guidelines are distributed to the provider community.

New Medicare beneficiaries enrolled on or after Jan. 1, 2005, will be eligible for a screening physical during the first six months of their enrollment. Previously, Medicare covered no physicals. Under the new benefit, enrollees may receive a physical examination, including measurements of height, weight, blood pressure, visual acuity and an electrocardiogram, but excluding clinical laboratory tests. The services will be billed under a new code: G0344, Initial preventive physical examination, and one of several new G-codes for the provision of the electrocardiogram.

Screening for diabetes is another new benefit mandated under the MMA. CMS proposed covered current procedural terminology (CPT) codes as CPT code 82947 Glucose; quantitative, blood (except reagent strip), CPT code 82950 Post glucose dose (includes glucose) and CPT code 82951 Glucose; tolerance test (GTT), three specimens (includes glucose). The final rule further defines factors for people at risk of diabetes and those with problematic glucose levels. The new benefit will be available Jan. 1 to eligible persons, not to exceed two screening tests per year.

The MMA expands Medicare coverage of cardiovascular screening blood tests beginning Jan. 1, 2005, to include cholesterol levels and other lipid or triglyceride levels. In the rule, CMS specifies that covered tests include a 12-hour fasting lipid panel consisting of total cholesterol, high-density lipoprotein cholesterol and triglyceride levels. The agency defines the benefit coverage period as one screening test every five years.

Physician scarcity areas will give certain rural providers a 5 percent bonus payment
Some Medicare physicians providing services in newly defined "physician scarcity areas" will be entitled to a 5 percent bonus payment beginning Jan. 1. Under the MMA, primary and specialty care physicians practicing in "scarcity areas" will automatically receive the bonus based on the zip code of the site of service and paid quarterly.

Primary care physicians eligible for the scarcity area bonus payment include general practice, family practice, internal medicine and obstetrics/gynecology. All other physicians will be considered specialists and eligible for the specialty care bonus payment. Dentists, chiropractors, podiatrists, optometrists and all nonphysician practitioners are ineligible for these payments.

The Centers for Medicare & Medicaid Services (CMS) identified zip codes for the bonus payments and posted them to their Web site. The lists identify areas that will automatically be assessed the 5 percent payment, as well as areas that partially fall into designated scarcity areas. Providers should further investigate if they qualify for the bonus payment and use the modifier -AR for claims identification. Anesthesia services (CPT codes 00100-01999) must use an -AR modifier to receive the bonus payment.
Certain Medicare services are not eligible for the bonus payments. These include the technical component of covered services, incident to services and therapy services. When billing a service that has a professional and technical component, claims billed globally will be returned as unprocessable for the bonus payment. Eligible services must be billed separately as a professional and technical component for payment.

To ascertain if your practice is eligible:
1. Determine whether the zip code for the site of service is listed on either the primary or specialty care scarcity area by referring the lists posted on the CMS Web site. If your zip code is listed, your practice will be automatically assessed an additional 5 percent bonus for claims on or after Jan. 1.
2. If your zip code is not listed, determine whether the county for the site of service is listed. If your county is listed, use the -AR modifier to identify claims eligible for the bonus payment.

CMS restricts therapy services to
professionals with therapy training
In the 2004 proposed Medicare physician fee schedule, the Centers for Medicare & Medicaid Services (CMS) solicited comments on qualifications for practitioners performing therapy services incident to a physician's professional services. The Agency in the 2005 proposed rule responded to the comments received and proposed to limit the coverage of services performed incident to the service of a physician, physician assistants, clinical nurse specialist or nurse practitioner. The final rule released on Nov. 2 adopts this policy change, effective on or after March 1, 2005.

-For incident to physical therapy services, the provider must meet the Medicare definition of a physical therapist or supervised physical therapist assistant. No state licensure to practice physical therapy is required.
-For incident to occupational therapy services the provider must meet the Medicare definition of an occupational therapist or supervised occupational therapist assistant. No state licensure to practice physical therapy is required.
-For incident to speech language therapy services the provider must meet the Medicare definition of a special language pathologist. No state licensure to practice physical therapy is required.

The proposal will not prohibit practitioners, including physicians, physician assistants, clinical nurse specialists or nurse practitioners who perform services under their own benefit and are licensed within the State to perform therapy services. In a clarification, CMS notes that athletic trainers were never considered qualified professionals to render covered Medicare services. They also modified the regulatory language to make clear that physician assistants, clinical nurse specialists and nurse practitioner may perform therapy services incident to a physician's professional service if licensed by state law.

Get more information
Learn more about the affects of the 2005 Medicare physician fee schedule final rule on group practices by participating in the Medicare Update 2005 MGMA Webcast on Dec. 2. Identify specific changes in coverage policy, including the new Welcome to Medicare physical, new codes recognized by Medicare, restrictions on physical therapy and more! Find FREE resources to ease the implementation of the 2005 fee schedule changes and prepare your practice for significant changes in billing requirements.
Evaluate the coding and payment implications of the drug payment changes for your group practice by participating in the Prescription Drug Coding and Reimbursement Under Medicare MGMA Webcast on Dec. 21. This audio will present a straight-forward explanation of the new government rules establishing the average sales price (ASP) drug payment formula, drug administration code changes and new billing guidance. Participants will take away tools to help plan for the impending changes to survive the significant decrease in revenue anticipated Jan. 1, 2005.

For more information, visit mgma.com or register today by calling 877.ASK.MGMA (275.6462, ext. 888)

Letter from the Medical Reserve Corps
The Medical Reserve Corps (MRC) is a nationwide, community-based organization that was developed by US President George W. Bush in response to the events of September 11, 2001. In the MRC, various public health and health care professionals such as physicians volunteer their services and educate residents of various communities how to live healthy and productive lives. This organization is sponsored by the Office of the Surgeon General, in cooperation with the White House's USA Freedom Corps and the Department of Homeland Security's Citizen Corps.

Recently, a local branch of the MRC called Detroit Medical Reserve Corps has been formed. We are inquiring if physicians of the Wayne County Medical Society would be interested in volunteering their time and medical expertise to educate our audience on various healthcare issues.

If addition information is warranted about the MRC, please visit the Website www.medicalreservecorps.gov. You can reach me via the above sources of contact. I look forward to hearing from you.
Thank you for your time and consideration.
Sincerely,
Apryl Brown
MRC Coordinator/Director