Friday, October 04, 2013

They are coming

I got an email from the supervisor of a bariatric program this week. Quite a few of my patients with severe insulin resistance and diabetes, obesity, have benefitted from their program. Indeed, I saw Mr. A just this week, having lost 77 lbs since his sleeve gastrectomy in summer. His a1c was 7.5% on 3 medications; it was now 5.6% on metformin alone.

"Dear Dr. Vagus,

Some of our colleagues in X state are reporting that RAC audits have been denying their payments, because adequate hormonal testing was not done to rule out adrenal/pituitary causes. What hormonal testing would you recommend for all our patients, to avoid this problem?"

Apparently, the auditors deemed thyroid studies to not be enough.
This is the dread we are expecting.
RAC audits; every clinic knows it's coming. And while it's not yet here, we all dread it like the looming debt ceiling dateline. You know it's going to hit.
Recovery Audit Contractors have audited claims for Medicare patients since 2010. And though I won't pretend to know how it works, rumor has it that the auditor gets to keep a cut of the "savings" from the claims they deny, and if so there is a financial incentive to be picky on issues of doctors' billing and to deny them.
In this case, I was dumbfounded. I see patients all the time, convinced their obesity is not related to their eating habits, or who get less than 1000 steps a day on their pedometers. Who think a Big Mac and fries is a normal lunch. And so when a bariatric surgery practice is telling me that they are expecting them to do a hormonal screen for all obese patients, I cringe.
Yes, the thyroid is a reasonable test to do; it's cheap and hypothyroidism is relatively common. But beyond that, to ask for adrenal/pituitary/other hormonal screens? So do we have to resort to doing a Cushing's screen for all obese patients, in the absence of clinical suspicion? Or IGF-1 (to screen for growth hormone deficiency)? Why stop there? We can do testing for Leptin deficiency or hypogonadism or some other obscure endocrine thing, too. I'm sure this won't add to an already burdened system.
In my 8 years of endocrine practice, how many Cushing's patients have I encountered? Maybe 20. How many patients with obesity (BMI>30)? Oh, I don't know, thousands? How many Cushing's patients that presented only with obesity and no other clinical findings? Zero.
Keeping in mind that obesity itself is a known cause of false positive cortisols. And may lead to hypogonadism.
So, tell me again you want your bariatric clinics to do a screen for all your obese patients.
RAC audits might have been started with the intent of saving money; but something tells me this is going to backfire.

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