Letters to the Editor - July 1999 - American Academy of Family Physicians

Letters to the Editor

Physician Reimbursement Issues in Home Health Care

TO THE EDITOR: We were thrilled to read an article devoted to home health care in a recent issue of American Family Physician.¹ Family physicians are increasingly called on to supervise simple and sophisticated medical care that is provided to frail elderly patients in their homes. We would like to clarify several important points.

To be eligible for home health care under current Medicare guidelines, the patient must require one or more of the following three primary skilled services: nursing, physical therapy or speech therapy. A need for either occupational therapy or social work alone would not qualify the patient for home health services. However, once services have begun, occupational therapy may be the only skilled component in continued care. Social work services, without other primary skilled services, do not qualify the patient for home health care that is covered by Medicare.²

We agree that physicians face financial barriers for full participation in the supervision of home health care. The physician receives no reimbursement for the detailed referral necessary to generate the home care plan. Only if the physician is able to meet the complex requirements of the care plan oversight codes is reimbursement available for physician supervision. However, reimbursement for physician house calls has increased dramatically in recent years. In our area of the United States, for example, reimbursement for a typical physician home visit (CPT code 99348) is approximately $60.

Medicare will cover the nursing and equipment costs of intravenous (IV) antibiotic therapy that is provided in a patient's home. The cost of fluids and antibiotics is generally not reimbursed by Medicare, so use of these therapies depends on billing the patient or another payer. This severely limits the physician's ability to supervise the infusion of fluids or antibiotics in the home for patients who are insured by Medicare.²

We encourage family physicians to master the rather arcane knowledge necessary to supervise Medicare home health.^2-4 Physicians should also advocate for coverage of other needed services, such as physician oversight, IV antibiotics, periodic venipuncture and the provision of unskilled services, such as bathing, in the absence of skilled needs.

RICHARD J. ACKERMANN, M.D.
TRACEY H. HUYCK, R.N.
3780 Eisenhower Parkway
Macon, GA 31206

REFERENCES

Montauk SL. Home health care. Am Fam Physician 1998;58:1608-14.

Marrelli TM. Handbook of home health standards and documentation guidelines for reimbursement. 3d ed. St. Louis: Mosby, 1998.

Steel K, Leff B, Vaitovas B. A home care annotated bibliography. J Am Geriatr Soc 1998;46:898-909.

American Medical Association. Physicians and home care: guidelines for the medical management of the home care patient. Chicago: American Medical Association, 1992.

IN REPLY: I would like to thank Dr. Ackermann and Ms. Huyck for their letter. As they are no doubt aware, the nuances of home care can be confusing. Their points on eligibility add significant information worth noting. My article should have read "A physical therapist may perform the initial assessment, and a nurse need not be involved." Their points on the lack of coverage for infusion medications are also well taken. Additionally, in most states, even patients who have Medicaid in addition to Medicare are poorly covered for intravenous medication; reimbursement is such that agencies often lose money on these patients.

Although I agree that physician financial reimbursement has increased dramatically, $60 per home visit is very little for physicians who do only minimal home care, such as those who wish to follow their long-term patients who have become homebound. Because I have a number of home care patients, I have the option to see three or (rarely) four in a two-hour period away from my office ($90 to $120 per hour to cover my cost and that of my office personnel and maintenance). A physician who goes to a patient's home that is 20 minutes away may only bill $60 for that hour (depending, of course, on the complexity of the visit). When I was in this situation before I increased my home care, I still made home visits a priority, but financial incentives (disincentives?) make it more difficult for many physicians.

SUSAN LOUISA MONTAUK, M.D.
Professor of Clinical Family Medicine
University of Cincinnati College of Medicine
P.O. Box 670582
Cincinnati, OH 45267-0582
E-mail: montausl@uc.edu

Male Dyspareunia in the Uncircumcised Patient

TO THE EDITOR: Male dyspareunia in the uncircumcised patient often results from balanitis xerotica obliterans (BXO), also known as lichen sclerosus et atrophicus.¹

Our patient was a 40-year-old Jewish immigrant from Russia who requested a ritual circumcision on an outpatient basis. He maintained good personal hygiene but had developed dyspareunia. Examination revealed balanitis xerotica obliterans. The glans and mucosa were white, smooth and atrophic, and the meatus showed erosion. Varicose veins were present on the dorsal mucosa of the prepuce. In addition, a very tight frenulum caused a frenular chordee² (Figure 1).

FIGURE 1. Genital balanitis xerotica obliterans that caused male dyspareunia. The glans was white, smooth and atrophic, and erosion was apparent on the meatus. In addition, the very tight frenulum caused a frenular chordee.
FIGURE 2. Immediately after the circumcision. Notice that the mucosa too was white, smooth and atrophic. The frenular chordee was resolved with lysis of the frenulum.
FIGURE 3. One month after circumcision. The condition greatly improved, and the patient resumed normal marital relations.

BXO is an inflammatory deteriorative condition. The scarring or sclerosis that may result can trigger, among other conditions, phimosis, meatal stenosis, pain on erection¹ and male dyspareunia.

BXO is not limited to adults. Children may also have BXO¹ and its related condition, posthitis xerotica obliterans³; however, these conditions are often missed.^1,2 Circumcision is the treatment of choice.⁴ Drs. Ledwig and Weigand reported that "we were unable to find a case of lichen sclerosus et atrophicus of the glans or prepuce in a male circumcised in infancy."¹

The Mohel (ritual circumciser) performed the circumcision on the patient in the usual sterile fashion on an outpatient basis (Figure 2). Post-circumcision care consisted of sitzbaths, an astringent wet dressing two times per day and applications of A + D ointment six to eight times per day. Treatment was discontinued after one month. The patient's condition improved, and he was able to resume normal marital relations (Figure 3).

RABBI JACOB SHECHET, MOHEL
P.O. Box 461911
Los Angeles, CA 90046

BARTON TANENBAUM, M.D., F.A.C.S.
Beverly Hills, CA

STANLEY M. FRIED, M.D.
Kaiser Permanente
Downey, CA.

REFERENCES

Ledwig PA, Weigand DA. Late circumcision and lichen sclerosus et atrophicus of the penis. J Am Acad Dermatol 1989;20(2 Pt 1):211-4.

Whelan P. Male dyspareunia due to short frenulum: an indication for adult circumcision. Br Med J 1977; 2(6103):1633-4.

Weitzner S. Posthitis xerotica obliterans in a 12-year-old boy. Am J Dis Child 1972;123:68-9.

Meffert JJ, Davis BM, Grimwood RE. Lichen sclerosus. J Am Acad Dermatol 1995;32:393-416.

Hypnosis in the Treatment of Hyperemesis Gravidarum

TO THE EDITOR: Patients with hyperemesis gravidarum are commonly seen by family physicians. Up to 90 percent of pregnant women have symptoms of "morning sickness," and some develop full-blown hyperemesis gravidarum.¹ This condition often leads to serious risks for the mother and her fetus, as well as lengthy and costly hospitalizations. Medical hypnosis may be a powerful adjunct to the typical medical treatment regimen, and empiric studies of the efficacy of this treatment approach for hyperemesis gravidarum are well documented.^2-3

In a study of 138 hyperemesis gravidarum patients who were completely recalcitrant to conservative medical treatment (consisting of antiemetic drug therapy, isolation by hospitalization and intravenous rehydration), 88 percent stopped vomiting completely after one to three sessions of medical hypnosis.⁴ Therefore, it may not come as a surprise that medical hypnosis has also been shown to be an effective treatment for hyperemesis secondary to chemotherapy^5,6 and hyperemesis secondary to "motion-sickness." In my clinical experience with hypnosis in the treatment of 30 to 40 patients with hyperemesis gravidarum, symptoms fully remitted within three or four treatment sessions in the overwhelming majority of patients.

Hypnosis may effectively treat hyperemesis gravidarum in at least two ways. One component of the treatment mechanism is that, in a hypnotic state, patients may be induced into a deep state of physiologic relaxation. This decreases sympathetic nervous system arousal, and symptoms associated with hyper-sympathetic arousal tend to remit. Further, it is well established that patients often respond to hypnotic suggestions that are independent of sympathetic or parasympathetic arousal and, interestingly, responsiveness is often independent of the patients' conscious awareness or memory of the suggestion. Patients may be given both indirect and direct suggestions to relax their stomach and throat muscles, causing their nausea, gagging and vomiting to subside. By suggesting that muscle tension in the stomach and throat and/or nausea become a hypnotic cue either to engage in particularly pleasant imagery or to hold cognitions that mentally reframe the experience, the nausea can immediately subside.

Before embarking on hypnotherapy to treat hyperemesis, patients should have a thorough medical evaluation to rule out other diagnoses. The differential diagnosis for hyperemesis gravidarum includes the following: gastroenteritis, cholecystitis, pancreatitis, hepatitis, peptic ulcer disease, pyelonephritis, fatty liver of pregnancy, pelvic inflammatory disease, appendicitis and hyperthyroidism. Patients may also benefit from a psychiatric evaluation if psychiatric co-morbidity is suspected, in which case a referral to a mental health practitioner may be warranted. Finally, while in 1958 the American Medical Association declared hypnosis to be a legitimate form of medical treatment, it should be emphasized that only an appropriately trained practitioner of medical hypnosis should apply this treatment.

ERIC P. SIMON, PH.D.
Department of Psychology
Behavioral Medicine & Health Psychology Service
Tripler Regional Medical Center
Honolulu, Hawaii 96859

REFERENCES

Broussard CN, Richter JE. Nausea and vomiting of pregnancy. Gastroenterol Clin North Am 1998; 27:123-51.

Torem MS. Hypnotherapeutic techniques in the treatment of hyperemesis gravidarum. Am J Clin Hypn 1994;37:1-11.

Fuchs K. Treatment of hyperemesis gravidarum by hypnosis. Aust J Clin Hypnother Hypn 1989;10:31-42.

Fuchs K, Paldi E, Abramovici H, Peretz BA. Treatment of hyperemesis gravidarum by hypnosis. Int J Clin Exp Hypn 1980;28:313-23.

Redd WH, Andresen GV, Minagawa RY. Hypnotic control of anticipatory emesis in patients receiving cancer chemotherapy. J Consult Clin Psychol 1982;50:14-9.

Redd WH, Rosenberger PH, Hendler CS. Controlling chemotherapy side effects. Am J Clin Hypn 1982;25:161-72.

The views expressed in this letter are those of the author and do not reflect the official policy of the Department of the Army, Department of Defense or the U.S. Government.

Corrections*

Two questions in the January 1, 1999 "Clinical Quiz" are incorrect or poorly worded. Question 5, pertaining to the article "Polivirus Vaccine Options" (page 113), is poorly worded. Choice A is better phrased this way: The IPV/OPV dosing schedule provides a 50 percent reduction in the cumulative number of cases of VAPP. Choice E is better phrased this way: It is always safer for children with congenital immunodeficiences. The correct answer to Question 5 remains E.

Question 15, pertaining to same article, is also poorly worded. An all-OPV vaccination schedule is only acceptable in special circumstances. The question is better stated this way: "Which of the following dosing schedules is/are generally acceptable for poliovirus vaccination?" The correct answers for Question 15 are A and B.

*These corrections have been made to the online version of AFP. The link above will take you to the corrected items, which remain part of the online issues in which they were originally published.

Clarification

In a letter to the editor on the use of melatonin for insomnia (April 15, 1998, page 1783), the author, Ray Sahelian, M.D., failed to disclose that he was the author of a book on melatonin.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

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