One of the most frustrating things that can happen to you in your teenage years is for you to experience acne. Not only is it difficult because of the way that it looks, they can be painful and they are frustratingly persistent. It is thought that hormonal changes in the body is what causes acne but there are also some other considerations as well. Regardless of what causes it, however, anybody that is suffering is sure to be looking for a cure acne treatment.

There are actually several different ways that you can treat acne. Many individuals go to the doctor in order to get a prescription but there are also some over-the-counter medications that are showing real promise. If your acne is particularly severe, you may also consider laser skin treatment for acne or perhaps something like a chemical peel. Although this sounds rather unsavory, they have shown promising results from these type of treatments.

For many individuals, however, they are looking for a cure acne treatment that is a little less harsh than going under the knife. To be certain, there are several different natural treatments that have also shown real promise according to those that have used them. Why would you use a natural treatment whenever your doctor may have a treatment that would help?

First of all, many natural treatments are derived from things that are commonly available in the house so they are less expensive than a medical treatment. Secondly, you can typically treat yourself without having to worry about any possible side effects.

Everyone has a snoring story to tell. Whether it is the time you woke up the whole house sawing logs as a kid, or the time your partner kept you up all night when you had a big meeting the next day, snoring is an all too common occurrence. Snoring is responsible for countless hours of lost sleep, and a good majority of couples sleeping in separate rooms. But what many may not know is that snoring can be a danger to your health in addition to bothersome. Research has shown snoring to be a cause of divorce or separation in many cases.

What causes snoring? Quite simply, snoring is caused by a partially obstructed airway. When you sleep, the soft tissue and muscles in your mouth and throat relax, causing your airway to become smaller. If your airway becomes small enough, your soft palate and uvula begin to vibrate when you inhale and exhale. These vibrations are the cause of the sound most people call snoring. This is very much like a reed musical instrument.

How common is snoring? According to recent sleep studies, approximately 45% of the general population, 30% of men and women over age 30, 40% of the middle-aged population, and 6% of children snore on a regular basis.

Is snoring dangerous? Forty five percent of normal adults snore at least occasionally, and 25 percent are habitual snorers. According to the Journal of American Medical Association (JAMA), snorers have three times as many motor vehicle accidents as non-snorers. Problem snoring is more frequent in males and overweight persons and it usually grows worse with age. Snoring sounds are caused when there is an obstruction to the free flow of air through the passages at the back of the mouth and nose. There are patients whose snoring has decibel levels as loud as jet engines and even some who have had neighbors in the apartment or even the house next door call the police to complain about the noise.

Can snoring be cured? Yes! Snoring can be cured by firming and toning the muscles in the throat and tongue. There is specific exercises design to target these muscles and tighten them and firm them up, to prevent them from becoming over relaxed and falling back in deep sleep causing snoring.

Relative value units (RVUs) quantify the different values of the different services that you provide. For example, the removal of an acoustic neuroma is assigned a higher number of RVUs than is the removal of cerumen. RVUs are published in the Federal Register each November. They are calculated on the basis of the amount of work required (which accounts for 46% of the total RVU), the expense to the practice (50%), and the cost of malpractice insurance (4%).

RVUs vary in different parts of the United States because they are adjusted in accordance with the Geographic Practice Cost Index (GPCI). If the cost of living in your geographic area is exactly the same as the national average, your GPCI is 1.0. Areas where the cost of living is higher and lower than average are assigned correspondingly higher and lower GPCIs. For example, the nationwide average number of RVUs that Medicare assigns to a tonsillectomy and adenoidectomy procedure (CPT 42820) is 7.54 in 2003 (was 8.21 in 2002). In Indianapolis, however, the cost of living is calculated lower than the national average, and this difference is reflected in our lower-than-average GPCIs for work (0.981), expense (0.922), and malpractice (0.481). Therefore, when the GPCIs for Indianapolis are factored into the equation, a tonsillectomy and adenoidectomy procedure here is assigned 7.06 RVUs in 2003 (was 7.69 in 2002). Note that the 4.4% reduction in the 2003 Medicare conversion factor ($34.59 vs $36.20 in 2002) plus t he 0.63 reduction in RVUs for CPT 42820 results in a 2003 payment (effective 3/1/03) of $244.51 vs $278.38. That is a 12.16% reduction.

Your software should be able to calculate and keep track of all the RVUs you generate (figure). To make such calculations, divide your revenue by the total RVUs to arrive at the revenue/RVU figure. Then total all your costs (except for physician-related expenses) and divide that figure by total RVUs to arrive at the cost/RVU figure. Once you know these figures, you can take steps to ensure that (1) your contracts are paying you more than your cost/RVU and (2) your revenue/RVU is greater than your cost/RVU.
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Finally, be sure that at least one of the parameters you use to determine your fee schedules is based on the 2003 Medicare conversion factor for RVUs.

Florida-based medical center reduces its claims denial rate by 70 percent.

“Leaving money on the table” seems to be this year’s catch phrase. But when you’re not collecting $1 million or more per month that is owed you because of claims denials, that translates to Big Money.

That was the case for West Florida Medical Center Clinic (WFMCC) of Pensacola, FL, with its 145 physicians and 13 satellite facilities in Florida and Alabama. With almost 50 percent of its patients covered by Medicare, ongoing denial of claims by Medicare posed a serious cash flow problem.

“As we got further into lower reimbursements, insurance companies and the federal government created more hoops for us to jump through to get paid for services. One of our challenges was to identify covered diagnosis- and carrier-specific rules related to coding so we could prevent claims denials,” says Lin Dworshak, associate administrator for business services at WFMCC.

Do the Math
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With the clinic generating between $13 million and $15 million in charges every month, the 10 percent of claims consistently denied by carriers for coding issues amounted to substantial uncollected revenues. “Denials came from diagnostic errors, procedure code incompatibility, unbundling and inclusive denials,” Dworshak says, noting that West Florida Medical officials had begun tracking the denial rate as early as 1998, in the days when most reimbursements flowed more freely than today.

Income due but not received was bad enough. But it was the correction process itself that steadily depleted the medical center’s resources. The process of correcting coding errors after the fact–after a physician determined a diagnosis code, after the claim was submitted and denied, after the WFMCC staff had to investigate, correct the codes and resubmit the claims–kept five FTE staff very busy and just as frustrated.

“We wanted to move the entire process back to the point of service,” Dworshak says, “back to the point of the physician or nurse who was making the decision about codes–and who would know, as those charges were entered at the point of service, whether or not those services were likely to be paid. Big bang happens at the point of service.”

While there were companies with batch programs that loaded the charges into accounts receivable (AR) and could identify the errors on a report, most solutions available at the time were still back-end solutions, Dworshak says.

Dovetailing Advances

“Making error corrections on your AR is a nightmare to deal with. You want to make as few corrections as possible to keep your AR as clean as possible,” she says. “We had the vision in 1998 to move the decision-making process back to the point of service, to the physician’s office where that charge originates.”

With few options available for front-end editing with a point-of-care focus, Dworshak and her colleagues were intrigued by the Claims Editor Professional (CEP) from ADP Context of Westmont, IL. It was one of the few that could take charges at the point of service, transaction by transaction, online and in a paperless process–while also determining, on the front end, whether the charges would be paid. Choosing ADP Context’s CEP product was a risk for West Florida Medical since the company was relatively new.

Because West Florida Medical was then upgrading its practice management system from a mainframe system to a UNIX-based product with true Windows, installing CEP at the same time seemed a good opportunity to dovetail two necessary technology advances into one action step.

The clinic made its purchasing decision soon after the vendor showed them proof. “They ran a batch of claims we had already filed through the editing product and proved that their edits would have stopped these claims prior to submission. In each case, it would have fixed the incorrect data and sent the claim through as clean–allowing us to be paid after the first submission.”

Installation and Beyond

In times past, Dworshak says, reimbursements were higher and rules were fewer. Cash flow was generally good, and although healthcare organizations did experience claims denials, they didn’t have to pay nearly as much attention as they are forced to today. “With greater emphasis on coding rules and with lower reimbursements, institutions are driven to get it right the first time to keep cash flow up.”

In addition to reducing the rate of claims denials, the clinic had three objectives in selecting the CEP solution:

1 reduce FTEs in the business office;

2 increase accountability with physician offices;

3 integrate the interface of the product with the clinic’s own practice management system.

“Throwing FTEs at a problem never solved the problem,” Dworshak says. More importantly, the business office continued to fix mistakes that were created in physician offices with very little feedback to those offices to prevent further occurrences.

CEP is client-server technology, which affords West Florida Medical more flexibility in customizing the product to the needs of the practice management system. Instead of keying into the AR system, “we keyed directly into CEP,” says Dworshak. “We would use that as our transaction entry product, have it scrub the claims online, review them for errors, fix those errors and then move them to our AR as clean claims–knowing they will be paid correctly the first time.”

Background: A recent cross-sectional study of 6700 Americans found that patients with chronic illnesses receive only half of the recommended care.1 Wagner et. al. developed a Chronic Care Model (CCM) to improve care of chronic disease, particularly congestive heart failure, asthma and diabetes.2 The CCM multidisciplinary approach combines community resources, patient self-management support, and clinical information systems. At the Rhode Island Hospital resident clinic (MPCU) we care for 800 patients with type II diabetes. Chronic disease management is challenging in our setting because of socioeconomic barriers, multiple providers, and large numbers of active medical problems. However, clinics similar to ours have improved their treatment of chronic disease using a CCM.

Methods: We created a pilot CCM program to improve treatment of type II diabetes at the MPCU. Ninety-nine patients, identified using ICD-9 codes and resident input, were enrolled in a computerized registry. After each visit, data were updated and a printed summary report was placed in the chart. The reports graphically depict trends in lab values and designate care that is due in a bold font. We educated residents about the program at a noon-conference lecture, in small groups, and via electronic mail. Patients were given educational and self-management materials and received a printed report at each visit. If overdue for an appointment, they were called and rescheduled. The pilot program continued for 6 months.

Results: At baseline, 30% of patients had a HgA1C of less than 7% and 54% met cholesterol treatment guidelines. These values did not significantly change over the course of this intervention but the number of patients who had these labs checked increased. Other parameters of care improved. Diabetic education increased from 14% to 23% and nutritional education from 8% to 16%. Documented foot exams improved from 33% to 38%. The number of patients on an ACE-I or ARB increased from 76% to 90% and the number of patients on aspirin went from 42% to 50%. The retinal exam rate did not change.

Collecting copayments and outstanding balances at the window is critical to surviving and thriving in today’s challenging practice management environment. There are two important reasons that you should encourage your staff to collect during face-to-face time:

* Copays are now $20 to $50 in many plans, not the $5 they once were. This is significant revenue.

* Collecting copays after a patient has left your office is not only difficult, but expensive.

Software is available that can provide you with a daily update of the payment records of every patient who is scheduled to be seen on any particular day (figure). Your staff should make an effort to collect these balances at the window so that you can minimize your practice’s collection-service fees for large unpaid balances as well as the expenses associated with pursuing smaller balances. You might also consider posting a sign in your reception area that advises patients, “If you are unable to remit your copay today, please see the receptionist so we can reschedule your appointment.”

A 27-year-old man with a history of epidermolysis bullosa came to the clinic complaining of progressive dysphagia. He had been unable to swallow solids or liquids for the previous 24 hours. Physical examination revealed the presence of fluid-filled blisters, scarring, and contractures over the dorsal surface of his hands (figure, A). Transnasal esophagoscopy detected an area of severe inflammation and circumferential sloughing of the mucosa in the middle portion of the esophagus, 24 cm from the nasal vestibule (figure, B). A narrow stricture 1 cm in length was seen just distal to the area of mucosal slough (figure, C).

In light of the significant risk that intubation poses in a patient with active epidermolysis bullosa, we elected to perform esophageal dilation in the clinic with Savary dilators (figure, D). Our technique for in-office dilation involves the direct visualization of the area of stricture with a transnasal esophagoscope. A Savary dilator guidewire is inserted through the instrument’s biopsy port. Then the esophagoscope is removed, leaving the wire in place as it passes through the stricture and out the patient’s nose. A Kelly clamp is used to reach into the patient’s mouth and withdraw the wire transorally. Progressively larger Savary dilators are then advanced over the wire to dilate the stricture. Our patient tolerated the procedure easily and did not require sedation. At the 4-month follow-up, he was still eating without difficulty.

Physicians’ Clinic of Iowa (PCI) is a 50-physician multispecialty clinic located in Cedar Rapids, Iowa. Physician specialties include cardiac surgery, otolaryngology, general surgery, neurology, orthopedic surgery, podiatry, rheumatology, thoracic surgery, urology and vascular surgery.

PCI employs 200 staff at five sites of care. PCI physicians manage approximately 98,000 E and M encounters per year and perform over 52,000 surgical procedures annually. In the spring of 2001, leadership at PCI decided to develop a quality program for the clinic.

After evaluating health care options and reviewing industry quality systems, it was decided to pursue ISO 9001 certification for the clinic. PCI leadership had joined the local chapter of the American Society for Quality and participated in chapter events. This relationship enabled PCI leadership to gain insight into quality management systems used in industry, and the information helped in choosing ISO as the quality system for PCI to pursue.

The International Organization for Standardization (ISO) was founded in Geneva in 1947. (1) The original purpose of the organization was to provide standardization of technical specifications for products traded in the international marketplace. The term “ISO” is a word derived from the Greek “isos,” meaning “equal.”

Over 150 countries are members of ISO, and there are more than 10,000 ISO standards used worldwide. These standards determine how various products and services are produced, and include standards for film speed, thickness of credit cards, compact disc format, and screw thread number. Standardization has served an important role in promoting quality and compatibility of products on a global basis. (2)

The work of standardization is performed by ISO technical committees comprised of representatives from interested member countries to address specific standards. Over the years the concept of standardization has evolved from specific technical specifications to a broader concept of generic quality management system standards.

The concept was first brought to the United States by the automobile industry in the late 1980s because of a need to qualify the thousands of suppliers used by the automobile manufacturers. This effort was a concrete example of competitors working together to develop a quality framework that would serve them and their customers.

Study objectives: Patients in a pulmonary clinic have disorders that predispose them to osteoporosis and may use glucocorticoid therapy, which has been associated with low bone mineral density (BMD) and increased fracture risk. Ideally, all patients at risk for osteoporosis would be screened using the best test available, which is central BMD by dual-energy x-ray absorptiometry (DXA). We proposed to stratify the risk for osteoporosis by the use of a simple questionnaire and point-of-care heel ultrasound BMD measurements.

Design: Cross-sectional screening study.

Setting: Pulmonary clinic in a single Veterans Affairs Medical Center.

Patients: Approximately 200 male and female patients who had not had previous BMD testing were eligible for the study, and 107 gave consent.

Interventions: One hundred seven men (white, 71 men; black, 35 men; and Asian, 1 man) underwent heel BMD testing and filled out a questionnaire. Ninety-eight men underwent a central DXA.

Results: Of 98 subjects, 24.5% had a spine, total hip, or femoral neck (FN) T-score of [less than or equal to] -2.5, which is the generally accepted definition of osteoporosis diagnosed using DXA, and 44.9% had a T-score of [less than or equal to] -2.0. The best-fit models for predicting FN or total hip BMD included body weight, heel BMD, corticosteroid use for [greater than or equal to] 7 days, and race, which accounted for 52 to 57% of the variance. When a heel ultrasound T-score of -1.0 was tested to predict a central DXA T-score of -2.0, the sensitivity was 61% and the specificity 64%. Adding the questionnaire score and body mass index (BMI) to the heel T-score improved sensitivity but not specificity. Moreover, BMI and age predicted central BMD with similar sensitivity and specificity. Importantly, of 24 patients with a central DXA T-score of [less than or equal to] -2.5, only 14 were identified by a heel T-score of [less than or equal to] -1.0.

Conclusions: Although the findings from a heel ultrasound plus the answers to a questionnaire were reasonably good indicators for predicting the presence of low BMD, little predictability was gained over the use of BMI and age. In a group of pulmonary clinic patients, the prevalence of osteoporosis was clinically significant, and central DXA testing was the preferable technique for identifying patients who were at risk for fracture.

The otoscopic view is that of a right ear in an asymptomatic patient. A large area of tympanoscierosis involves the anterior and inferior portions of the pars tensa. This is cosmetic and is not producing fixation of the tympanic membrane or the ossicular chain. There is slight retraction over the incus. The pars flaccida anterior to the malleus is also slightly retracted. At the posterior annulus and external auditory canal, an accumulation of cerumen is present. Although this ear should have regular, routine observation to detect any progression of the retraction of the pars tensa, it is probably stable and will require no treatment.