Melissa Young, MD

Endocrinologists and other physicians in “cognitive” specialities have long lamented that our healthcare system values physicians who work with their hands but not those who work with only their minds.

For example, a surgeon who performs one single-vessel coronary artery bypass graft gets paid the equivalent of about 20 moderately complex office visits. We can spend hours seeing patients, educating them, managing the intricacies of the social and behavioral aspects of their care, and try to keep them from needing surgery, and make infinitely less than our colleagues who perform procedures. Endocrinologists are, in fact, among the lowest-paid specialists.

The 2021 E&M changes were supposed to level the playing field a little. The rates for new patients are decreasing, but not by much for the more complex patients that endocrinologists typically see. The reimbursement of each outpatient follow-up visit, however, is going up.

There is a snag there however. In addition to changing the reimbursement for each code, they are also changing the criteria necessary to reach each level. This change was allegedly made to decrease the administrative burden of documentation in each note. Gone are the points necessary in the physical exam and review of systems. Great. Sort of. I’m still going to perform a comprehensive exam and ask for an extensive review of systems.

My patients have disorders that affect every organ system, so I’m still going to examine and ask about symptoms relating to the nervous, cardiovascular, gastrointestinal, urinary systems. I’m still going to have to ask about smoking and drinking. And quite honestly, with an electronic medical record, clicking on those boxes is easy. And because my patients have multiple related medical issues (for example those who have diabetes almost invariably have hypertension and hyperlipidemia), and they need labs and tests and meds and specialist referrals, the visits quite commonly reached the highest level of complexity, a 99215.

With the new criteria, these same visits may not make the cut for a level 5. It might be doable if we consider insulin a drug that requires monitoring for toxicity. In my mind, it absolutely is. After all, insulin accounts for over 100,000 ER visits a year and 9% of all ER visits due to drug-reactions. And yet the AMA singled out insulin specifically in its description of an exclusion, stating that “monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern). That is just absurd.

Ah, but we were being consoled because to offset this problem, there was an add-on code, G2211. This was to be tacked on to a bill for “visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or medical care services that are part of ongoing care related to a patient’s single serious condition or complex condition”.

This was supposed to provide an additional payment to reflect the time, intensity and practice expense required to build longitudinal relationships with patients and to provide care for them over an extended period of time. Endocrinologists and many other non-procedure based specialists, as well as primary care and family physicians, could have used this code on the majority of our visits, finally giving some value to the “in-between visit” work we do every day.

Why past tense? Why “could have”? Because in a last minute decision, use of this code has been delayed for 3 years. Why? Because the changes in coding and reimbursement are made within a structure that keeps the overall budget neutral. What does that mean?


It means they need to rob Peter to pay Paul. So, when these changes were proposed, the organizations and societies of the “cerebral” specialists supported it, but those of surgical specialties did not, as their reimbursement was likely to decrease.. And in the end, once again, the surgical Peters won and us Pauls lost.


The alleged decrease in administrative burden is unlikely to be tangible, and certainly unlikely to increase productivity. And as such, while the expense of running a practice in 2021 will continue to increase, reimbursement will almost certainly decrease. As one colleague put it “I feel like endocrinology is a dying field. I can’t keep going like this”.

Articles

Dr. Melissa Young, a practicing endocrinologist, offers her perspective on E/M changes set to take effect in January 2021. 

Melissa Young, MD: An Endocrinologist's Perspective on E/M Changes in 2021 

2020 has been quite the year. Australian and West Coast wildfires, protests, a tight and highly contested election, and, of course, a pandemic have made it a year of much upheaval. Lives have been lost and even more lives have been changed.

I will admit, when the news of COVID-19 first hit, I was among the people who said, “people die of the flu every year, and we don’t shut everything down. This is the same. Yes, unfortunately, the sick and infirm may not survive it, but the rest of us can calm down and carry on”. Boy, was I wrong.

When a 50-year-old woman in a neighboring parish choir got sick and died, I thought “they could be describing me”. When the public health emergency was declared and the quarantine started, we had to make some quick decisions about the practice.

At first, people started canceling appointments. I had still foolishly hoped that things would be over in a couple of weeks—just like they said school would be closed for two weeks. So we just rescheduled them to the next available spots, but as the pandemic grew and the patient volume dwindled, major changes had to be made.

We started offering telemedicine visits as an option for those who didn’t want to come in. Then, as the incidence of coronavirus infections grew, we switched to all virtual visits. There were some patients who embraced it, others who accepted it begrudgingly, and those who somehow felt no interaction was better than an electronic one and rescheduled.

The schedule, which had been practically empty for a few weeks began to fill up again. As the COVID statistics improved, we were able to offer in-person visits again although I still strongly recommend telemedicine for my older patients who have other risk factors for a more complicated infection. We are now almost at full capacity with a mixture of in-person and telemedicine visits. I am worried about the next few months as the incidence starts rising again. I am hopeful that at this point more people are comfortable with telemedicine and we won’t have too many straight-out cancellations.

To complicate things financially, in addition to loss of revenue due to fewer office visits, there have been additional expenses. I have had to purchase personal protective equipment (PPE) for myself and my staff. I have had to buy additional cleaning supplies. Not that we never cleaned things before, but never to this extent. And what’s worse is that the cleaning products are ruining the surfaces of the exam tables, doorknobs, etc. Kills 99.9% of germs and everything else, I guess. I have purchased touchless soap dispensers, hand sanitizer, infrared thermometers, plexiglass barriers. And, of course, there are the usual expenses—salaries, insurance, utilities, rent.

I applied for a Paycheck Protection Program loan in the spring. I also received some of the CARES act grant. I don’t think I would have been able to keep my staff if I did not receive those funds.

Even now, we have not completely recovered from the loss of revenue and I struggle each pay period to keep things afloat. I have even forgone my own paycheck to be able to keep up with bills. We actually did ok at the height of the pandemic because claims from the beginning of the year were being paid. But since claims were down from April through July, the money coming in now is a lot less than usual. It doesn’t help that Medicare recently rejected several thousand dollars’ worth of claims because of a code they chose not to cover.

I recently applied for additional funds through part 3 of the CARES act. As part of the application, I had to compare revenue and expenses of 2019 versus 2020. Let’s just say, it was quite the eye-opener. Prior to that, I had kept being hopeful, saying, “yeah, we’re ok, we’re down a little, but it’ll be ok”. That spreadsheet was like a kick in the head. No, we are not okay. And another bad quarter could be devastating.

Having said that, I remind myself every day that thus far, this pandemic has been a major inconvenience to me, but nothing more. My family is healthy, I am healthy, I still have a job and a business, my husband still has a job. Not every family can say this.

We have had our scares, we have been frustrated by the craziness of virtual education, we worried about not having enough toilet paper or meat. But the kids are “going” to school, we haven’t run out of toilet paper or meat. We have had more family time. We live in a time in history when we can reach out to and “see” family thousands of miles away. When we can purchase food, medicine, clothes, and yes, toilet paper online. We can watch Broadway shows on our computers and movies on our phones.

COVID 19 continues to affect our lives, our work, our world. We must continue to do what we can to stay safe, to stay afloat. For me, I’ll keep doing what I’m doing. Providing care for my patients, employment for my staff, income for my family. In the safest way I know how.

Dr. Melissa Young, an endocrinologist, reflects on her experiences during 2020 as part of the My Year in COVID-19 feature series. 

Melissa Young, MD: My Year in COVID-19

I joined the American Association of Clinical Endocrinologists in 1999—just 8 years after it was founded and during my first year as an endocrinology fellow. I was encouraged to do so by my mentors as it was an organization designed to support practicing endocrinologists. I became a Fellow of the American College of Endocrinologists (which is through AACE) in 2004.

It was so important to me at the time to attend the induction ceremony that I went even though I was just a few weeks postpartum. So the baby and I traveled (along with my sister who agreed to watch him while I attended the ceremony) so I could receive my scarf and medal. I have since proudly put the initials FACE after my name.

When I was in training and then as an employed physician, it was much easier (and cheaper) for me to attend annual national meetings. Some years, I would attend both the Endocrine Society and the AACE annual meetings. I preferred the AACE meetings because they were geared more towards clinical practice, whereas ENDO had many basic science lectures, which while fascinating didn’t help me with the day-to-day management of my patients. Later, the demands of private practice and motherhood, as well as the expense of both, led me to attend less frequently. I did, however, attend our state’s chapter meetings.

AACE also had a political advocacy group, one that would bring our concerns about reimbursement and policy to congress and CMS. I say “had” because it was unfortunately dissolved. I don’t remember why, really. Perhaps lack of participation or support from the membership, perhaps it was felt that there were other similar groups that could do the job. Nonetheless, AACE was the organization that I and many other practicing endocrinologists turned to for education, practice support, clinical guidelines and national policy change.

Like many other things in 2020, things have drastically changed in AACE. Things that many of its members are unhappy with.

Let’s start with the name. It is no longer the American Association of Clinical 

, but the American Association of Clinical 

. Now, this may seem like a minor change to many, but to those of us in practice, it suggests that the organization is no longer 

 us, that it is no longer “a professional community of physicians specializing in endocrinology, diabetes and metabolism committed to enhancing the ability of its members to provide the highest quality of patient care” as its mission used to say.

In fact, they have opened membership to anyone willing to pay the dues. At a time when fellowship-trained endocrinologists are struggling every day against the tide of non-endocrinologist practitioners (both physician and nonphysician) who claim to be “hormone experts”, allowing them to claim membership to AACE gives them a veil of legitimacy.

This is a serious concern that endangers patients. Patients have a hard enough time figuring out who a real endocrinologist is without these practitioners flaunting their membership on their website or Facebook page.

Another change that has come about is the loss of support and recognition of state, regional, and international chapters. Throughout the country and the world, there were dozens, if not hundreds, of AACE chapters—each providing support and education to local endocrinologists. From what I understand, this was a financial decision. OK, fine. Most chapters plan on carrying on independently, but here’s the catch.

We are apparently not allowed to use the terms “clinical endocrinologist” or “clinical endocrinology” in the name of the new organizations because those are supposedly intellectual property of AACE. We fail to see how they can lay claim to what is a generic term. Our chapter has been told that legal action will be taken if we insist on using “clinical endocrinologists” in our name.

And lastly, my beloved FACE. In order to become a Fellow, there are certain criteria you must meet. You must have formal training in endocrinology and professional experience in endocrinology and you must have letters of recommendations from either a Fellow or Master of ACE.

So, once inducted, you have proven yourself to be a board-certified or eligible, formally trained practicing physician. Up until recently, once a FACE, always a FACE, provided you maintain your membership.

Now, in addition to maintaining fellowship, there are additional requirements. Granted, they are not onerous, and since we all must maintain a certain number of CME credits and participate in educational activities anyway, all FACEs would probably be able to meet the requirements. But it is being objected to in principle. At a time when many are complaining about MOC and recertification, and how neither of those reflect what we do in the trenches, requiring that we “prove” ourselves to ACE annually rubs us the wrong way.

As a result of the above changes, many private practice endocrinologists are upset and have vented their frustrations on social media. A couple of AACE’s board members have come forward to justify the changes. One said that thousands of people were asked and that the large majority were in favor of the changes. When asked who these thousands of people are, it turns out, they were non-endocrinologists.

Not everyone understands why we are so perturbed by these changes, and we have even been chastised for not wanting the public to be included or informed. That is certainly not the case.

We have no objections to providing patient education on the website and there can be links to clinical information for healthcare professionals. But endocrinology is one of the few specialities that still has a decent population of solo private practitioners and small practices, and many feel abandoned by what was our advocate. The board says that has not changed, but if the membership grows due to the addition of new members who are non-endocrinologists, naturally, the board and consequently the organization is going to have to cater to the needs and wants of those members, leaving small private practices in the dust.

We fight everyday not just against disease, but against insurance companies, government red tape, and internet misinformation. Et tu, AACE?

A practicing endocrinologist offers her thoughts on a recent change by the AACE from the American Association of Clinical Endocrinologists to the American Association of Clinical Endocrinology.

Melissa Young, MD: An Open Letter to the AACE Regarding Their Name Change

This article is the last in a 3-part series titled “

Collaborative Care: Technology’s Evolving Role in Cardiometabolic Health

". Learn more about this feature series. 

Even though there are many other medications we can use for diabetes now that weren’t available a decade or two ago, many people still need to take insulin, and for patients with type 1 diabetes, insulin is life-sustaining.

“We’ve come a long way, baby,” as the old advertising slogan says. The methods of insulin administration, glucose monitoring, and data gathering are much different now than they were 2 or 3 decades ago.

Let’s start with insulin administration. I have older patients who balk at the idea of taking insulin because they remember their parent or aunt or uncle who had to use reusable glass syringes to draw insulin from a vial. These were later replaced with plastic syringes. No more need to resterilize the syringe, just use a brand new one every time!

Of course, drawing insulin into a syringe still requires significant dexterity and good up-close vision to ensure that the correct dose is drawn up—and there are still patients who prefer this method due to cost or habit. Meanwhile, every endocrinologist will tell you about that patient who was not doing it correctly and was drawing up air. No wonder the glucose levels never improved.

Along comes the insulin pen. This device allows patients to just dial to the number of units they need. This decreases the risk of giving an incorrect dose. It also made insulin more portable. Patients can carry a pen and few needles with them. No need to worry about keeping the vial refrigerated (although spare unused pens must be stored in the refrigerator) when they are out. No need to worry about dropping the vial and breaking it, losing days’ maybe weeks’ worth of medication. And the pen has evolved over time, too. The first few were refillable with replaceable cartridges. While those are still available, most insulins are now available in disposable pre-filled pens. There are also reusable pens that can tell you when you took your last dose and how many units you took. One can even be linked to an app that can calculate the insulin dose for the patient and estimate their insulin-on-board.

Even before the first insulin pen came out in 1985, the first insulin pump was developed. The first one was huge—about the size of a backpack—and certainly not convenient enough for everyday use. Over the last 3 or 4 decades, they have become smaller and more feature-packed. There are the traditional tubed-pumps and the “tubeless pump”. All pumps give a basal rate (a small amount of insulin that is continuously given throughout the day) and the patient can also make the pump deliver boluses of insulin for meals or to correct hyperglycemia. Since the infusion site generally only needs to be changed every 3 days, that means the patient can give him or herself 3, 4 even 10 doses of insulin through the day without having to puncture the skin more than once every 3 days. It gives patients more flexibility with meals and work.

The majority of patients who transition from multiple daily injections (MDI) do better on a pump. Now, there are even pumps that are integrated with continuous glucose sensors and two that can change the basal rate based on the data from the sensor. This decreases the risk of severe hypoglycemia and hyperglycemia.

This brings me to the continuous glucose sensor. Most patients tell me that one of the worst parts of managing their diabetes is checking their blood sugar. Although most patients don’t want to start taking injections such as insulin, once they’ve done it, they say the discomfort from doing an injection pales in comparison to the pain of having to prick their fingers. After all, fingertips are much more sensitive than the thigh or abdomen, and lancets have a larger diameter than insulin needles so that blood can come out.

Continuous glucose sensors allow patients to have nearly unlimited data about their glucose without the pain of frequent fingersticks. Patients are still advised to do periodic fingerstick testing either to calibrate the sensor or to confirm an abnormally high or low sensor reading, but they don’t have to do it as often as they have if they did not have a sensor.

Furthermore, many CGM systems have alerts. They can beep or vibrate to let the patient know that their glucose is dropping or rising too quickly before they have any symptoms of hypoglycemia or before their glucose is dangerously high. This is especially important in patients with hypoglycemia unawareness. A CGM can be a life-saver in someone who does not get the adrenergic warning symptoms of hypoglycemia.

As a physician, I recommend pumps and sensors to many of my patients for the benefits described above. In addition, the data that can be downloaded from the devices can help me fine tune their regimen. I look for patterns in their glucose and in their behavior. I can see how many carbs they have on a Friday night vs a Wednesday night and I can show the patient what happens when they have 100g of carbs versus 45g. I can see if their glucose is dropping in the middle of the night and can adjust their pump settings accordingly. I can see if they are missing doses on insulin, skipping meals, forgetting to turn the pump back on after they shower. Then we can work on correcting the behavior.

Insulin therapy and glucose monitoring has definitely changed the way diabetes can be managed and more improvements are sure to be developed in the next few years. The holy grail, of course, would be a device that both monitors glucose and delivers insulin with one site, and automatically delivers both basal and prandial insulin. That day is something many of my patients are looking forward to.

Dr. Melissa Young details the evolution of technology in diabetes management from the perspective of a practicing endocrinologist. 

Melissa Young, MD

Articles

Melissa Young, MD: An Endocrinologist's Perspective on E/M Changes in 2021

Melissa Young, MD: My Year in COVID-19

Melissa Young, MD: An Open Letter to the AACE Regarding Their Name Change

The Evolution of Technology and Diabetes Care