After trying over-the-counter sleep aids for months, I finally broke down and requested a prescription for Ambien, Ativan, Xanax, or other. My neph’s nurse called back and said a new law went into effect on the 1st (Jan?) requiring that patients be seen w/in 3 weeks of the scripts being written and will continue as long as the patients uses the medication.
This is impractical for any med that will be used indefinitely.
I haven’t heard of such a law. I’d ask the nephrologist’s nurse to alert you to where you can find information about the law and whether it’s a federal or state law. You might want to ask your doctor which of the sleep aids has the fewest side effects.
Sleep aids can cause problems for some people. A while back my ex-husband mistakenly took Ambien in the morning thinking it was another pill and shortly after he “sleep drove” to work, tearing up the side of his new car on the highway guard rail without even knowing it and without responding to police who were trying to get him to stop. When he got to work he noticed the rear view mirror hanging off the car, but it made no impression on him. He walked into his office, got coffee, read the paper and then started wondering about the damage to his car without remembering incurring the damage. After seeing the car, recognizing that the damage was real and not a dream, he talked to one of his co-workers who suggested he needed to see a doctor. He drove himself (how they let him do that is beyond me) to the hospital, went to the ER, explained the accident and no memory of it. Because he didn’t remember taking the pill, they hospitalized him to rule out other causes. After a day when no other possible causes were found, I asked if he had taken Ambien (having seen the ads that talk about doing things while sleeping with no memory of them). When he got home and counted pills, he called me to tell me that he had taken Ambien that morning. Luckily he didn’t hurt himself or anyone else on his “sleep drive” and the car was repairable.
Whether there’s a law or not, I think it’s a good idea to see the prescribing doctor after you’ve been taking a sleep aid for a while to see how it’s working, what side effects you’ve noticed, etc. How often did the nurse said you’d need to see the doctor? You should be seeing your nephrologist monthly as a home patient. That would be a good time to do that follow up.
The nurse called back to let me know that by law, I have to be seen within 3 weeks of the initial prescription so they would have chart notes of the doctor discussing the med with me. After that, apparently, I would not be required to see him every 3 weeks for refills. That makes more sense, although I have been discussing the sleep issue and different meds with him for months. He will prescribe Ambien but will not prescribe Ativan for me. I think his office has some issues with prescribing meds to patients. Something must have happened to someone for which they suffered repercussions. Additionally, he said I should see a sleep specialist and that I am beyond the ‘adjustment period’ for nocturnal indicating that I should have no problems sleeping now. I’m not going to waste time or money to see a sleep specialist who will comfirm the obvious - the problem keeping me from a sound sleep is dialysis. I have no problem sleeping on my nights off.
Your husband is very lucky. That was a scary and expensive lesson for him I guess. He actually prescribed Ambien for me 2 years ago when I had restless legs. The medication that is supposed to work for restless legs (Requip) didn’t plus kept me wide awake so he prescribed Ambien along with it. The combo made me vomit for 12 hours the next day. Over the next 2 years I have on occasion taken an Ambien as a last resort without the previous side effects. I just finished the last one yesterday. My point is, I’ve had the medication and am aware of its effect. But I can see its a good practice to see patients within 3 weeks. I could see some docs never seeing someone but still prescribing meds.
I also don’t see my neph every single month. I do see my nurse every month in clinic because I have to pick up supplies. That monthly visit is more than adequate most of the time unless I have issues or questions. I think (correct me if I’m wrong) that by law I must see either a nephrologist or nurse practioner once a month as a home patient. Since my neph is over an hour away, and my nurse is also an hour away, if it’s not necessary every single month, then I’ll skip one month with my neph here and there. He still gets paid whether I see him or not and I still must pay a copay even if I don’t see him which I disagree with.
Medicare reimbursement rules changed for physicians to get their monthly capitated payment. In the past, physicians didn’t have to see home patients to get the rate equal to 2-3 visits for in-center patients. Starting 1/1/2011, physicians or practitioners (I believe this includes nurse practitioners, clinical nurse specialists, and physician assistants) are supposed to see home patients once a month to get that reimbursement. However, the Medicare payers are allowed to waive that requirement on a case-by-case basis if the physician or practitioner’s documentation indicates that he/she has provided active and adequate care to the patient during the month. Here’s the new policy.
As you may or may not know, physicians must see in-center patients at least once a month. A nurse practitioner, clinical nurse specialist or physician assistant may see the patient other times so the physician can get Medicare reimbursement up to to the maximum of 4 visits a month.
Wendy, most prescription sleep aids lose their effectiveness over time. Some are also addictive. If you are only not sleeping on dialysis nights, I wonder what it is (exactly) about the dialysis that causes sleep problems. Do you have a hard time falling asleep, staying asleep, or both? Do the machine noises keep you awake? Is the light on the screen too bright? Are you worried about tossing or turning and disconnecting the lines? Or do you have trouble relaxing your vigilance? Depending on the exact problem, there may be a solution that doesn’t rely just on meds–although they certainly have their place.
Another approach to managing anxiety, that’s the issue, is cognitive behavioral therapy. Though working with a CBT counselor and practicing techniques at home people learn how to change thoughts and behaviors that are bothering them. http://www.anxietynetwork.com/hcbt.html
Here’s an abstract of a study that compared the two approaches in dealing with anxiety and they appear to be comparable in relieving anxiety and other symptoms.
Finally, if you’re not satisfied with nocturnal dialysis, you may want to consider short daily dialysis instead.
Beth and Dori,
Thank you both for your time and information. I am continually amazed at your dedication to this list and I appreciate it very much.
After all this time, I realized I could silence the alarm for reaching UF goal. It was a simple adjustment. I woke up every night to silence that alarm and rarely went back to sleep. These past 2 nights, I have slept through until the heparin pump beeped signaling “near end of treatment”. Tech support won’t tell me, the patient, how to turn the alarm off so now, I program the heparin to go beyond my treatment time in order to avoid the alarm. Happy to say, there has already been a big improvement. I do have a bad shoulder that bothers me most nights but I’ve even been able to sleep better with that.
When I first started nocturnal, I heard about all these people who slept through the night without problems. When I found out some (or most) took sleep aids like ativan, I said I would rather go back to short daily than take a sleep aid. It’s not an easy choice. My goal is to live longer and healthier so I had to weigh the risk of lack of sleep against the risk of prolonged sleep aids to the increased benefits of nocturnal dialysis over short daily. Hopefully, now that I’ve been able to make a machine adjustment, that will help and I can benefit from nocturnal without the use of sleep aids. My shoulder is another issue…
Again, thankyou very much for your dedication here!
[QUOTE=Beth Witten MSW ACSW;20667]Medicare reimbursement rules changed for physicians to get their monthly capitated payment. In the past, physicians didn’t have to see home patients to get the rate equal to 2-3 visits for in-center patients. Starting 1/1/2011, physicians or practitioners (I believe this includes nurse practitioners, clinical nurse specialists, and physician assistants) are supposed to see home patients once a month to get that reimbursement. However, the Medicare payers are allowed to waive that requirement on a case-by-case basis if the physician or practitioner’s documentation indicates that he/she has provided active and adequate care to the patient during the month. Here’s the new policy.
As you may or may not know, physicians must see in-center patients at least once a month. A nurse practitioner, clinical nurse specialist or physician assistant may see the patient other times so the physician can get Medicare reimbursement up to to the maximum of 4 visits a month.[/QUOTE]
When one is doing well on home txs, especialy nocturnal txs., I feel it is overkill to be required to come to monthly appointments, especially if one’s neph performs very unprofessionally receiving his fee without being required to prove patient satisfaction. Don’t get me wrong- if one has a professional behaving neph, I’m sure they wish they could see him more often then once a month for his professional expertise. But with home patients doing nocturnal it would seem that quarterly visits are more than enough if one’s neph is not provding good care. So, my question is, does ones neph still get paid if one occassionally chooses not to attend the waste of time and $ appointments that these appoints are for many of us?
I agree. As an established patient, I also feel it’s unnecessary to spend the gas money to drive an hour each way, pay $10 in parking, and spend 10 minutes in my neph’s office giving him updates. I do skip a month here and there but I am still charged a copay and my insurance still pays automatically on the first of every month whether I am there or not. I do know my neph and home hemo nurse talk occasionally on the phone. However, I question whether this is justification for a $400 payment every month. I compare this to my oncologist who is a huge reason why I am alive today. I saw him often - a few times a week at some points. His office visits were a third of the price of my nephrologist. I spent much time with my oncologist in heavy discussion about research either one of us had done. He has responded to at least a hundred or more detailed emails and phone calls from me plus he has spent countless hours conferring with other doctors on my behalf. My time with him was intense and difficult. He is the one that unquestionably should be receiving much more money than he ever got, bless his soul. It doesn’t sit right with me to pay a doctor month after month when it’s not necessary. I know dialysis doesn’t always go smoothly but when everything remains the same month after month after month, I question the spending. I would agree to quarterly visits - especially if you have a good home hemo nurse as I do.
Frequency of MD visits is written into the Medicare regulations, but regulations can be changed if there is enough will to advocate for change. I suspect this would be a tough sell, as CMS would worry that folks might get lost in the shuffle and important information missed. It’s terrific that you feel well enough on nocturnal to not need such close medical supervision!
Wendy, it sounds like you have a phenomenal oncologist. What a blessing to have someone who is so caring and spends so much time helping you. I’m not sure how or why payment differs between different medical specialties, but he sure sounds like he deserves everything he makes!
What sort of shoulder problem do you have? Is it frozen, by any chance? I’m thrilled to hear that you’ve made a machine adjustment that’s letting you sleep better!
They should be able to allow for exceptions in the monthly visit requirement just as they are with the face-to-face requirement for monthly payment.
Yes, I will never meet another human being so completely dedicated to helping save his patients’ lives. He gave himself to all his patients the same way he gave himself to me. God made only a few of him, I’m sure. Surviving is the greatest gift I could ever repay him with.
My shoulder began with an old softball injury that I re-injured playing tennis 2 years ago. MRI’s show tearing, spurs, impingment, tendonitis, and arthritis etc. I’ve had 2 shots of cortisone but I don’t see how I can avoid surgery at some point. It affects the quality of my life far more than dialysis does! There are too many things that I can’t do with my son because of it Maybe I need to address this before transplant.
The monthly visit is required by the dialysis regulations. The intent of that requirement is that home patients should not receive worse care than in-center patients. The dialysis regulations state that patients may not come occasionally but that the dialysis staff need to evaluate why patients are missing and how they’re doing to be sure they’re not having unidentified problems or skipping treatments. The dialysis regulations allow a patient to see hisher local doctor if that doctor and the nephrologist communicate effectively about the patient’s status and the local doctor sends his/her office visit notes to the dialysis clinic.
The bigger barrier to patients choosing to see their doctors less than every month is the Medicare reimbursement policy, which requires the nephrologist or other provider (another doctor, advanced practice nurse or PA) to see the patient occasionally for the nephrologist. I believe (but am not sure of this) that the nephrologist would need to have an arrangement (contract) with that non-nephrologist provider to reimburse him/her for the visit if the nephrologist himself/herself doesn’t have enough contact with the patient and/or home training nurse about the patient during the month to justify billing for the “monthly capitated payment” without a face-to-face visit with the patient.
[QUOTE=Beth Witten MSW ACSW;20703] The intent of that requirement is that home patients should not receive worse care than in-center patients.
Funny thing is that when I was in center, I never once had a doctor visit me in clinic. I drove to them. When I changed centers to one closer to me, I was assigned a new doctor who I never met. I was having problems and symptoms and called her office many times only to be brushed off by her staff. This went on for over a month until I changed doctors again. She never once came in to the center to talk with me and I never got in to speak with her - her ‘schedule’ was always full according to her staff. I found out after the fact that she continued to order high doses of epo when my hemoglobin was well above 12. I don’t think she ever checked my labs. I think it’s ironic in a way that their ‘intent’ is that home dialysis patients not receive worse care than in-center patients when their desire to limit the number of treatments we receive at home is ultimately assuring that we do not receive any better care than in-center patients.
Do you know if the center’s home hemo nurse qualifies as a provider for the Medicare requirements? She is the one whom I know pays attention to my treatments and status. She is the one that I go to first with any questions or concerns.
I don’t believe the home training nurse would qualify as a “provider” under Medicare’s reimbursement policies, I do know that as long state laws allow it, the dialysis regulations allow a nurse practitioner, clinical nurse specialist or physician assistant to fill in for a physician in all functions (patient assessment, plan of care meetings, prescribing, etc.) except those that the dialysis clinic’s medical director is supposed to do.
So far as the care that you received in-center, if that was prior to October 2008, that care was under the prior regulations and the requirement for the physician or provider to see patients monthly was not in the dialysis regulations or in the reimbursement rules for physicians. Because of the change, physicians won’t get paid for months they don’t see their patients or document in the medical record enough contact with those patients or with the home training nurse about their patients.
I am concerned that home patients who do not to see their physicians as often as the Medicare dialysis regulations and reimbursement policies require might have problems down the road. There are physicians who want to be in more control of their home patients and hate to lose money who would threaten to (or actually) “fire” a patient who doesn’t come for appointments with him/her either at the dialysis clinic or at his/her office. I have heard horror stories of patients who were fired by their doctors when the doctor became frustrated with the patient. If no other doctor in the clinic’s practice accepts the patient, the clinic has discharged the patient because there was no physician to write orders. In the case of a home patient, if no physician is willing to prescribed home dialysis supplies and the clinic won’t follow the patient, the patient would have to change clinics and doctors and may not even be able to get home dialysis much less the type of dialysis he/she wants to do. I’m not trying to scare anyone, but just trying to alert you to what could happen.
I’d suggest that you talk with your doctor about the barriers you have that make seeing him/her monthly difficult and determine if another approach can be worked out within the dialysis regulations and Medicare payment rules that will get the level of physician supervision you need and payment he/she deserves.
In all respect, I have read your reply a few times hoping to get what I must be missing. Here’s the problem I see with your explanation - and I understand that I could be missing some information that would change my perception. You said doctors may not be willing to see home dialysis patients because if they didn’t see them every month they wouldn’t get paid. The problem I see with that is that (good) doctors are interested in providing the care that is needed for patients. Good doctors are not interested in getting a stipend because they have recruited a certain number of patients as it would be in the situation you describe above. For example, when I was having chemotherapy, I saw my oncologist weely sometimes several times a week. He got paid every time I saw him. As I stabilized my visits decreased. As recurrences ceased I saw him monthly. Now I haven’t seen him in a couple of years (yet he still calls me with scan results every 3 months). My need to see him decreased when I stabilized and lessened more with an improvement in my status. The slots that I used to fill in his schedule were always full with patients who truly needed his care more than I did.
I worries me to think that the only reason to see a nephrologist every single month is not driven by patient need but by a physician desire for a stipend. If we condone paying medical staff out of fear that they will fire us if we don’t, that seems like extortion to me. People should see and pay for a doctor when they need the doctor’s help. If they don’t need or use their services at any particular time, then they shouldn’t simply pay to keep their spot. Somethings not right if that’s going on.
I’m not referring to patients that should be seeing their doctors and whose doctors spend time each month behind the scenes with true medical care. Yes, the doctors of course should be paid. I am referring to patients who are stable, where no changes or issues are going on, and where little or no medical coordination is being done by the nephrologist. No, they shouldn’t be paid that month.
I’m sure Beth will jump back in, too. The big difference, I suspect, between oncology and nephrology is that oncologists are actually trained to CARE FOR people who have cancer. If you go to one, you are quite likely to actually get informed consent–be given your options, what each of them might mean for your lifestyle, and be told the likely chances of success with, say, chemo, radiation, surgery, or a combination.
That’s often NOT the case with nephrologists. Their training may NOT focus on how to CARE FOR people with kidney failure. Rather, it may focus largely on renal physiology (acid-base balance and such) and, most importantly, research (often bench science). I have had nephrologists tell me that they were told in their fellowship training, “Don’t worry about dialysis–the nurses will handle it. You’re here to do research.” Some fellowship training programs don’t even cover in-center hemo, let alone any form of home treatment. The Board exam for Nephrology has 240 items. Only 5% focus on any type of dialysis. So, a nephrologist could pass that exam with a 95% score and still know nothing about dialysis. Obviously that’s an extreme and not very likely. But it’s possible under the current exam–and it shouldn’t be! IMHO, lack of MD knowledge about dialysis is one of the biggest barriers to more folks going home. Nephrologists don’t want to be asked questions they can’t answer. And, clearly they believe in home treatments for themselves, since they’d choose home overwhelmingly if their OWN kidneys failed. The Nephrology Board exam may be a good part of the reason why 91.7% of U.S. folks on dialysis are on standard in-center HD.
In the in-center setting, often nurses run the day-to-day show. In some clinics, apparently nephrologists weren’t even bothering to do the “Howdy Doody” rounds (coming around and waving at all of the patients). You can imagine why, when their training doesn’t prepare them for dialysis and they’re uncomfortable not really understanding it well… Medicare put in rules that they could only get paid if they actually showed up! Those rules would not have been needed if they were showing up in the first place. No doubt, it was a small minority who didn’t, and I know lots of caring, dedicated, knowledgeable nephrologists who DO care. But, some don’t. And that’s who the rules were for.
I read your post a couple of times and again, I can’t find where it points to valid, ethical reasons to pay the nephrologist for work not done.
Actually, to me, it supports reasons to NOT pay. Unqualified dialysis nephrologists is actually a separate issue from getting paid for work done instead of numbers recruited. The problem in your reply is untrained nephrologists. I don’t see how promising to pay stipends to nephrologists who are unqualified in dialysis in the first place will ever ‘motivate’ them to become skilled in dialysis. It would do just the opposite - become a nephrologist because they can get bonus payment for dialysis patients without ever having to know it.
Trained or untrained, I still fail to see how it’s ok to pay people for work not done. Again, I absolutely agree and want nephrologists and all medical professionals to get paid when they actually do work behind the scenes. I don’t think it’s right that they should expect payment simply because they have a dialysis patient - especially when some of the home hemo nurses do the bulk of the work anyway (as mine does).
What am I missing here? I hope down the road I look back at my posts and see how silly they are.
The Medicare reimbursement policy for dialysis in the past paid nephrologists who followed home patients whether they actually saw patients or not because it was assumed that they were on call 24/7 and responded to patients’ and nurses’ questions during the month even if they didn’t see patients every month. The old regulations did not specify that home patients had to be seen monthly and some patients were seen in clinics monthly, others every 6 weeks and some less often, especially if they had to travel long distances. I have worked in dialysis long enough to remember my first dialysis clinic seeing patients from western KS quarterly and other patients every 6 weeks.
The new regulations require that patients be seen by a physician, nurse practitioner, clinical nurse specialist or PA monthly, whether they are treated in-center or at home. The change in Medicare reimbursement policy requires the nephrologist or other practitioner to see the patient monthly or to have documented sufficient involvement in the patient’s care during the month before Medicare will pay the monthly capitated payment. Medicare will no longer pay nephrologists who don’t see their home patients monthly or have another practitioner see them.
The fact is that I’ve known patients who believed they were doing well and who had a health problem that was identified in a patient clinic that led to a hospitalization. One home patient at my last clinic came to clinic and just happened to mention that her leg was cold. She hadn’t called beforehand and apparently didn’t think it was cause for much concern. She was immediately hospitalized, but died when the blood clot that had disrupted circulation in her leg traveled to her lung. You are probably more aware of your body and would call if you had a problem like this, but it doesn’t hurt to have a “tune up” regularly when you have a chronic illness that has the potential for complications and take medications that may not work as they should or may have adverse side effects. If a clinic visit can save your life or improve your quality of life, it may be worth the time and effort.
Perhaps one thing that might make it less burdensome would be if home dialysis clinic appointments could be scheduled outside normal working hours or if dialysis clinic staff could see patients at an alternate site if there were enough patients in that area to warrant that.
[QUOTE=Wendy Ramsay;20741]Hi Dori,
I read your post a couple of times and again, I can’t find where it points to valid, ethical reasons to pay the nephrologist for work not done.[/QUOTE]
I wasn’t responding to whether or not they should get paid–just to the possible differences between oncology and nephrology.