Specialty Focus 11/5/24: Not medically necessary + Inside the ER

November 5, 2024 | Volume XIII | Issue 45

Inside the ER: What my visit taught me about patient care

Gregg J. Stefanek, DO writes for KevinMD:

For the second time in my life I visited the ER. I woke up early yesterday morning with unremitting, 7.8/10 left lower back pain accompanied by chills, nausea, and vomiting. Why 7.8? Well, I definitely could have imagined pain worse than an 8, but it seemed bad enough to go to the ER, so it surely must be worse than a 7, right? Just like all my patients, I have a strong pain threshold, right? Ever notice how many people end sentences with the word right? Having diagnosed many a kidney stone in my day, I was pretty convinced that was what I had (I had been taking a fair amount of antacids lately), so I did not object to a non-contrast CT scan to confirm what I suspected, even though the urinalysis did not show any blood. When the scan came back negative, and after the Toradol and morphine had eased my discomfort, the doctor suggested a contrasted…

Not medically necessary

T. Christian Miller, ProPublica; Patrick Rucker, The Capitol Forum; and David Armstrong, ProPublica

Every day, patients across America crack open envelopes with bad news. Yet another health insurer has decided not to pay for a treatment that their doctor has recommended. Sometimes it’s a no for an MRI for a high school wrestler with a strained back. Sometimes for a cancer procedure that will help a grandmother with a throat tumor. Sometimes for a heart scan for a truck driver feeling short of breath.

But the insurance companies don’t always make these decisions. Instead, they often outsource medical reviews to a largely hidden industry that makes money by turning down doctors’ requests for payments, known as prior authorizations. Call it the denials for dollars business.

The biggest player is a company called EviCore by Evernorth, which is hired by major American insurance companies and provides coverage to 100 million consumers — about 1 in 3 insured people. It is owned by the insurance giant Cigna.

Physicians, hospitals decry 2025 Medicare payment rates

Rebecca Pifer reports for Healthcare Dive:

The Biden administration has finalized 2025 Medicare reimbursement rates for physicians and hospital clinics that providers agree aren’t large enough in light of rising costs.

Physicians will see their Medicare rates drop 2.9% next year. The decrease, which is in line with regulators’ initial proposal this summer, means $1.8 billion less in funding going to doctors in 2025.

Meanwhile, the CMS finalized a 2.9% rate update for hospital outpatient departments and ambulatory surgery centers, up from the 2.6% regulators proposed...

Easy tips to decrease vitamin D deficiency

9 News

It's estimated that about 40% of Americans have insufficient levels of vitamin D and about 25% are considered deficient.

Vitamin D deficiency can lead to a loss of bone density, which can contribute to osteoporosis and fractures (broken bones). Severe vitamin D deficiency can also lead to other diseases. In children, it can cause rickets, a rare disease that causes the bones to become soft and bend. African American infants and children are at higher risk of getting rickets. In adults, severe vitamin D deficiency leads to osteomalacia. This condition causes weak bones, bone pain, and muscle weakness.

Watch the video HERE.

Last Word

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